puerperium Dr.F Mardanian MD

puerperium Puerperium : Is period during which the reproductive organs and all the system of the body returns to their normal condition following the delivery of the placenta and Ends approximately 6 weeks later.

puerperium When the endocrine influences of the placenta removed the physiological changes of pregnancy is reversed

Puerperium increase in blood volume . hypercoagulable state. Maternal physiology is well prepared for hemorrhage: increase in blood volume . hypercoagulable state. the “tourniquet” effect of uterine contractions.

MECHANISM OF HAEMOSTASIS AFTER DELEVERY Uterine contraction & retraction Platelet aggregation  clot formation

The Principal Changes Uterine Involution :

Uterine involution : Uterine involution : After the delivery of baby the uterus (myomaterial muscle )is well contracted & retracted and become at the level of the umbilicus , and after 10 – 14 days the uterus well become as pelvic organ.

Uterine involution : Breast feeding leading to release of oxytocin from the hypothalamus & posterior pituitary aiding the process of involution & more contraction & retraction of the myomaterial muscle of the uterus and decrease the incidence of post partum hemorrhage

Uterine involution At the time of the delivery uterine weight about ( 1 Kg) then after few weeks become 50 -60 gm and shrinks at the process of autolysis .

Full bladder Uterine involution Sub-involution of the uterus this occur when the uterus is not completely contracted & retracted which well leads to post partum hemorrhage and this mostly due to : Full bladder

Retained products of placenta Uterine involution Retained products of placenta

Infection at the uterus Uterine involution Infection at the uterus

Para-vaginal haematoma Uterine involution Para-vaginal haematoma

2 - endometrium The deciduas castes off as result of ischemia and lost as lochial flow . The lochia consists of blood , leucocytes , shreds of deciduas and organisms . The lochia is initially dusky red but this color fades after the first week and the flow usually clears completely within 4 weeks of delivery . The new endometrial will grow from the basal areas of the deciduas but this will influenced by breast feeding.

3- cervix Cervix is very flaccid and curtain –like after delivery but within a few days is returning to the original form and consistency . The cervical channel become closed to a finger during the second week of Puerperium .

4- Vagina The vagina almost , always shows evidence of parity . In the first few days of puerperium , the vaginal walls are smooth , soft and edematous . The distention which has resulted from labor remains for a few days but the return to the normal capacity quit quick . the episiotomies or vaginal and perennial tears healed well provide adequate suturing has been undertaken . Healing may be impaired in the presents of infection or haematoma but even if this happens, healing by granulation is usually occurs.

5- Other systems During the first few days the bladder and urethra may show evidence minor trauma sustained at delivery but don't usually remains in evidence for long . The physiological hydroureter & hydronephrosis will disappears within 6 weeks . there is usually a diuresis during first day of the puerperium and there is fall in plasma volume.

Active mangement 0f 3rd stage of laboure Inspection of placenta & lower genital tract

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 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.

Complication of puerpruim Serious , and sometimes fatal complication arise during puerprium , the most serious complication are : thrombus – embolism ( D. V . T and pulmonary embolism .

Complication of puerpruim Deep veins thrombosis and pulmonary embolism is now one of main causes of maternal death and the majority of deaths occur during the puerpuim .

Complication of puerpruim Infection . post partum hemorrhage primary & secondary

PPH . . . the most common and severe type of obstetric hemorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

PPH Causes Uterine atony in 70% of cases . -Retained Placenta -Trauma to birth channel. -Coagulation disorders -Uterine inversion c

Complication of puerpruim Injury to the birth canal .

UTERINE INVERSION Mostly iatrogenic due to mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus / adherent placenta.

Complication of puerpruim Urinary complication . Breast infection

Puerperal infection Puerperal pyrexia : which may be due to infection in: respiratory tract infection . pelvic organs( Site of placenta =Endometritis). U. T . I . surgical wounds . breast infection & abscess . thrombo phlebitis .

Puerperal pelvic infection Before the introduction of antibiotic , it was the most important cause of maternal death . now rarely results on maternal death and although it can still present as acute life – threatening illness , it more frequently occurs as low – grade infection which causes both immediate and long – term morbidity . It is important that pelvic infection are diagnosed and treated as early as possible .

Puerperal pelvic infection Pathology : At delivery , the normal protective barrier agonist infection are temporarily broken down.

Puerperal pelvic infection this gives an opportunity for potential pathogens to ascending infection to the decidua and placenta site . spread infection to myomatium , parametrium Fallopian tubes , ovaries ,& peritoneum.

Puerperal pelvic infection If virulent infection , the organism reach the peripheral circulation and the patient develops sings of septicemia and end toxic shock . it is more common for the infection to remain localized in the pelvis , and if treatment is not immediate and effective , there is danger of chronic pelvic infection with tubal blockage .

Puerperal pelvic infection Predisposing factors : prolonged P. R . M. a protacted labour with multiple vaginal examination . retained products of conception in the uterus . blood clots in the uterus . prolonged labour .

Puerperal pelvic infection Organisms : Gram ( + ) : B – hemolytic streptococci is the most virulent Other streptococci & staphylococci may cause acute clinical picture . Gram ( - ): more common to find coliform such as E . Coli or bacteroides fragilis . clostridii .

Puerperal pelvic infection Chlamydia : more recently , there has been interest as a cause of pelvic infection . anaerobic infection . difficult to culture . it can cause chronic problems of vaginal discharge , adhesion and tubal blockage .

Puerperal pelvic infection Clinical features : Puerperal pyrexia associated with : Offensive lochia. lower abdominal discomfort . In abdominal or bimanual examination : Uterine tenderness aggravated by moving cervix . Swelling beside the uterus or in the pouch of Douglas. Evidence of peritonitis , septicemia and bacteraemic shock , at this stage : patient acutely ill , restless ,dyspnoeic with high swinging Temp. tachycardia , dehydration and have rigors .

Puerperal pelvic infection Diagnosis : Made by : clinical grounds . And confirmed by culturing : high vaginal swabs , cervical canal swab urethral swab , and blood culture for aerobic and anaerobic should be taken

Puerperal pelvic infection Treatment : after taking swabs for C.S : the initial choice : combined broad spectrum antibiotics ( one of cephalosporins = cephradin 1 gm / 6 hourly ) + metronidazole 500 mg / 6 hourly and this to provides a wide rang of activity agonist Gram (+) and Gram ( -) organisms . The treatment in I .V line for (24- 36 hours) and till response has been achieved .

Puerperal pelvic infection When the symptoms are less acute change to the oral route and treatment should continued for at least 10 days . If there is no improvement we should change antibiotic according to the culture and sensitivity. If there is retained placental tissue within uterine cavity, this should be removed under G.A. If there is pelvic abscess should be drainage .

Urinary complication The commonest urinary complication in puerperuim is : Urinary injures . Infection . Urinary retention . Urinary incontinence .

Puerperal mental disorders the puerpruim is frequently associated with feeling anxiety and depression and acute psychiatric disorders .