Normal and Abnormal Puerperium Liu Wei Department of Ob & Gy Ren Ji hospital

Normal Puerperium Definition The time from the delivery of the placenta through the first few weeks after the delivery. 6 weeks in duration. 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 Reproductive organs 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 Cervix it never returns to the nulliparous state. the external os is closed to the extent that a finger could not be easily introduced. 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 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. 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 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初乳(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 Systemic change 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. Hematologic changes Hemoglobin concentration↑on the first postpartum days Several clotting factors (fibrinogen) ↑on the first days

Normal Puerperium Manifestation Fever (24 hours) Pain (uterine contraction) Sweat Lochia 恶露 a large amount of red blood initially flows from the uterus as the contraction phase rapidly occurs. (5 weeks) lochia rubra; lochia serosa (brownish red, with a more watery consistency); lochia alba (yellow)

Normal Puerperium Management 2 hours after delivery Bleeding Uterine contraction HR and Bp and R and T 1 weeks after delivery

Normal Puerperium Emiction and defecate Lochia Episiotomy and Laceration Breast

Puerperal Infection Puerperal Infection any 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 factors PROM Anemia Hemorrhage EP and CS Placenta retain

Puerperal Infection Common pathogens Aerobes Group A, B, and D streptococci溶血性链球菌 Gram-negative bacteria: Escherichia coli大肠杆菌, Klebsiella克雷伯氏菌 Staphylococcus aureus葡萄球菌

Puerperal Infection Anaerobes Petococcus species消化球菌 Petostreptococcus species消化链球菌 Bacteroides fragilis group脆弱类杆菌 Clostridium species梭状芽孢杆菌 Other Chlamydia trachomatis沙眼衣原体 Mycoplasma species支原体

Puerperal Infection Manifestation Acute vulvitis vaginitis and cervicitis Uterine infection Adnexal infections Septic pelvic thrombophlebitis 血栓性静脉炎 Sapremia 败血症

Puerperal Infection Diagnosis History Physical examination and PV Lab finding Differential diagnosis

Puerperal Infection Treatment Nutrition: anemia prevention Antimicrobial treatment broad-spectrum, high dose, long time Drainage Treatment of thrombophlebitis

Late Postpartum Hemorrhage Definition Uterine bleeding by 24 hours after delivery. Etiology Placenta or membrane or decidua retain Abnormal redintegration Infection Problems of incision

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