The Puerperium

normal and abnormal

Osama M Warda MD

Professor of obstetrics & Gynecology

The definition

Puerperium: is the period of 6-8 weeks

following the delivery of the fetus and

placenta.

It is the period taken for the uterus and

other body systems return to the pre-

pregnant condition. Also lactation is initiated

during this period.

Many changes do occur within the first 2

weeks of puerperium.

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Endocrine changes

Removal of the placenta affects the

physiological state; rapid clearance of

hormones from the placenta and

extra-cellular fluid.

HPL------disappears from serum by 1-

2 days

hCG------detected in serum for 2

weeks

AFP------disappears after several

weeks

High levels of E & P ------rapid loss3O Warda

Endocrine changes

cont., Ovulation function-----low for 2 weeks.

FSH/LH ----suppressed during

pregnancy remain low for 2 weeks

following birth, both in lactating and

non lactating women, however,

gradual increase occurs over 6 weeks.

The puerperium can be considered a

period of “natural infertility”

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Placental site

Dramatic decrease in size brings

uterine walls into close apposition and

transforms uterus into hard globular

mass.

This has the effect of applying

pressure on the placental site-----

prevents bleeding.

Diameter from 18 cm---to 9 cm

Promoted by continuous action of

pitocin.5O Warda

Uterine involution

Immediately after birth the uterine

weight is 1000 grams.

By day 5 uterus is 500grams

At the end of puerperium, it is 50-60

grams, and no longer palpable

abdominally.

Uterine involution may be due to

withdrawal of placental hormones.

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Uterine involution cont’d.

Uterine involution occurs due to 3 processes:

1. Ischemia: occurs as a result of collapse of blood vessels.

2. Autolysis: is a physiological process by which involution of the uterus is achieved. Breakdown of the intracellular protein by proteolytic & hydrolytic enzymes.

3. Phagocytosis: disposes of elastic /fibrous tissue.

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The Endometrium

Regeneration begin 1-2 days after

childbirth.

Differentiation into 2 layers :1. Superficial : barrier to infection

2. Basal : source for regeneration

Regeneration takes about 2-3 weeks.

Placenta site regenerates slowly over

6-7 weeks

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Lochia

It is a characteristic postnatal discharge

that reflects the process of involution and

restoration of the endometrium.

Mean duration 21-33days; shorter in

multipara and with small babies.

It runs in 3 stages:1. Lochia rubra: fresh blood from placenta

2. Lochia serosa: brownish pink after 4 days

3. Lochia alba: whitish discharge.

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Cervix and vagina

(after vaginal delivery)

Cervix is bruised, swollen ,

edematous, and little tone

By end of 1st week cervix decreased in

size , and closed by the end of 2nd

week.

Vagina is smooth, edematous, pouting

& bluish.

Vaginal rugae appear after 3-4 weeks.

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Cardiovascular Changes

Following birth dramatic changes in hemodilution cardiovascular instability.

Cardiac output elevated for 1-2 hours after birth . Begins to stabilise after about 10 min. Decreases until 10th day. Normal by 2 weeks.

Cardiovascular system reverts to normal in 2 - 4 weeks.

Days 2 -5 diuresis dissipates the extra cellular fluid, up to 3 Kg weight loss.

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Coagulation system

Profound physiological changes in the blood and dramatic changes in coagulation and hemostaticmechanisms.

Changes protect women from hemorrhage.

Levels remain high for 10 days

DVT/PE – increased risk if trauma, sepsis, immobility 13O Warda

Blood volume changes

Decreases rapidly over 24 hours.

Increase in hemoconcentration,

hemoglobin rises.

By 6-9 weeks returned to normal.

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Urinary tract

24-48 hours rapid diuresis –> decreases

plasma volume of blood to non-pregnant

levels.

High estrogen augments effects of ADH

- increases blood volume

Larger quantities of nitrogen from

autolysis

Trauma to bladder base, edema

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Post-natal visits: aims

To provide sound family planning information and advice

To care for and monitor the progress of the mother in the postnatal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the newborn infant

To examine and care for the newborn infant; to take all initiatives which are necessary in case of need and to carry out immediate resuscitation

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ABNORMAL PUERPERIUM

1. PUERPERAL PYREXIA

2. POSTPARTUM HEMORRHAGE

3. PUERPERAL SEPSIS

4. URINARY TRACT PROBLEMS

5. THROMBOEMBOLISM

6. PSYCHIATRIC PROBLEMS

7. OTHERS: a) bowel problems,

b) musculo-skeletal problems,

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Puerperal Pyrexia

A temperature of 38.0°C or higher, which occurs on any 2 of the first 10 days postpartum, exclusive of the first 24 hours, and which is taken orally by a standard technique at least four times daily. (Joint Committee on Maternal Welfare)

Some common sites of infection causing puerpural pyrexia

– Chest

– Throat

– Breasts

– Urinary tract

– Pelvic organs

– Wounds – cesarean, perineal

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Puerperal Pyrexia cont.

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CAUSE DESCRIPTION

Genital tract infection -Tender bulky uterus.

-Prolonged bleeding/pink or discoloured lochia.

-Painful inflamed perineum.

-Most common infective organisms; Escherichia coli, Group A

streptococcus spp., Staphylococcus spp.

Urinary tract infection -Frequency in micturation, painful micturation, haematuria.

-Rigors seen in cases of pyelonephritis

-Most common infective organisms; Escherichia coli, Proteus

spp. and Klebsiella spp.

Mastitis -Painful, hard, red breast abscess

-Nipple trauma and cellulitis

-Most common infective organism; Staphylococcus spp

Postoperative infection

(following Cesarean

section)

-high risk of postpartum septicaemia, wound problems and

fever

-Usual presentation; Painful, red suture line, tenderness on

deep palpation, lochia pink/coloured.

Deep venous thrombosis -Caused by venous stasis.

-Painful, swollen calf.

Others -Viral infection or chest infection.O Warda

Puerperal pyrexia cont.

Causative organisms

1– Aerobic organisms include beta-

hemolytic streptococci, Escherichia coli,

Klebsiella, Proteus mirabilis,

Pseudomonas, Staphylococcus aureus,

and Neisseria.

2– Anaerobic organisms include

Bacteroides, Peptostreptococcus,

Peptococcus, and Clostridium

perfringens. 20O Warda

Puerperal Pyrexia;

management Full examination of chest, breasts,

legs, lochia and bimanual vaginal

examination should be done.

Majority of infections originate from

the urinary or genital tract.

Caused by poor sterile technique,

delivery with significant manipulation,

cesarean birth, or overgrowth of local

flora.

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Post-partum hemorrhage

Primary PPH is defined as bleeding from

the genital tract of 600 ml or more in the

first 24 hours following delivery. Such

bleeding usually occurs very

unexpectedly due to retained placental

tissue or birth canal trauma.

Secondary PPH - bleeding occurs after the

first 24 hours of delivery until the end of

the puerperium.

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Type Timescale Presentation Predisposing

factors

Primary

haemorrhage

In the first 24

hours

Fresh bleeding, often

severely

heavy. Uterus may be soft

and

poorly contracted with the

fundus still above the

umbilicus

Uterine atony [90%]

Trauma, vaginal or

cervical

lacerations, labial

tears

Coagulation

disorders

Secondary

haemorrhage

After 24 hours

and up to 6

weeks

May be fresh loss or old,

altered blood, often

malodorous. The

uterus may feel soft, poorly

contracted and possibly

tender,

with the cervical os open

Retained products

of

conception

Endometritis

Dysfunctional

bleeding

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Puerperal Sepsis

It is a fibrile changes occurring during puerperium due to invasion of genital tract by pathogenic bacteria.

Sites of infection: Wound: mainly the placental site and

wounds of the perineum, vulva, vagina or cervix.Dead tissue: usually blood clots, and retained placental fragment.

Predisposing factors: General: as anaemia, ante partum

hemorrhage, post partum hemorrhage, malnutrition and toxaemia.

Local: as lacerations, sloughing and premature rupture of the membrane.

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Puerperal sepsis cont.,

Signs and Symptoms: Headache,

Raised temperature,

Vomiting,

Dry tongue and lips.

Abdominal examination revealed a supra pubic tenderness and rigidity. The perineum, vulva, vagina or cervix are become infected and lochia is foul smelling.

Treatment: The primary goal of treatment is concerning the

causes and its predisposing factors for the infection.

At this time lactation and physiotherapyprogram should be stopped until fever disappear. 25O Warda

Urinary tract problems

1- Urinary retention or voiding difficulties: may occur postnatally secondary to painful tears involving the bladder or use of epidurals in labor.

Retention occurs usually immediately after delivery and is partially due to the sudden decrease in intra abdominal pressure: –> there is a decreased stretch reflex response following bladder filling.

Methods that can encourage micturation

–early ambulation

–pelvic floor exercises

–hot baths

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Urinary tract problems cont.

True incontinence occurs rarely but is

usually associated with a vesico-

vaginal fistula

After surgical repair, the patient is to

undergo physiotherapy to strengthen

the pelvic floor muscles.

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Thrombo-embolism

Risk of thromboembolism rises 5 fold during pregnancy & puerperium

Majority of deaths occur in the puerperium

The symptoms and signs of venous thromboembolism:

– leg pain and swelling (usually unilateral)

– lower abdominal pain – low-grade pyrexia

– dyspnoea – chest pain – hemoptysis

– Calf muscles are tender and painful on firm palpation.

If DVT & pulmonary embolism is suspected >>>

– bilateral venogram and/or lung scan should be carried out within 24-48 hrs.

– full anti-coagulant therapy (heparin) should be started immediately.

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Psychiatric Problems

Divided into three conditions based on their severity

1–”Baby blues”

2–Postpartum depression

3–Postpartum psychosis (most severe, may result in suicide/infanticide)

A syndrome seen among fathers is linked to the mood changes of their wives. May be due to the added responsibility of having a child and decreased attention from the wife.

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Psychiatric problems;

manage.1-Postpartum blues: no specific treatment

other than support and reassurance from family members and friends.

2–Postpartum depression: exclude medical causes (eg. thyroid dysfunction), individual/group psychotherapy for mild cases, medication (antidepressants)/ hospitalization/ electro-convulsive therapy for moderate to severe cases.

3–Postpartum psychosis: Inpatient treatment with medication (mood stabilizers-eg. lithium/valproic acid) and/or electroconvulsive therapy.

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Other Problems

Bowel problems:

- Haemorrhoids are a common

problem after childbirth, exacerbated

by bearing down during the second

stage of labor.

–Treatment: Local application of 5%

lidocaine gel or anusol

(hydrocortisone) cream together with

bulking agents (eg. Psyllium, fiber) to

soften the motions.32O Warda

Other problems

Musculo-skeletal problems:

1– Painless divarication (spreading

apart) of the recti: can occur

antenatally due to the enlarging uterus

that exerts pressure on the recti,

causing them to separate.

– Treatment involves

exercises that increase

muscle tone.

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Other problems

Musculo-skeletal problems:2- pelvic joints pain:

- In pregnancy the pelvic ligaments become more lax and the symphysis pubis will separate to some extent. This is beneficial as the anterior-posterior diameter is increased.–In extreme situations the hemi-pelvices

can be widely separated causing severe pain making walking difficult.–Treatment: Milder cases: Analgesic &

orthopaedic beltSevere cases: Zimmer frame and

bed rest34O Warda

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Normal non-pregnant pelvis

Total gap width of up to 9mm is normal

during pregnancy

Abnormal gap is considered to be ≥ 10mm

(note misalignment)

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Orthopedic belt

Zimmer frame

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Thank You

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