Problems of the Puerperium Max Brinsmead MB BS PhD May 2015

Day 1 Primary postpartum haemorrhage Primary postpartum haemorrhage –Beware of the patient who “trickles” –Some objective measure of loss desirable Hypertension and seizures Hypertension and seizures –Continue Mg sulphate for 24 hrs –Look for a diuresis –Keep BP below 150/100

Day 1 cont.d –Urine retention Aggravated by trauma or PV pack Aggravated by trauma or PV pack Check voiding ? catheterise Check voiding ? catheterise –Urine Incontinence Await spontaneous resolution Await spontaneous resolution Exclude fistula Exclude fistula Analgesia Analgesia –Perineal pain Exclude paravaginal haematoma Exclude paravaginal haematoma This requires evacuation This requires evacuation –After pains NSAID useful NSAID useful But not for hypertensive patients But not for hypertensive patients

Day 2 – 6 weeks Secondary postpartum haemorrhage Secondary postpartum haemorrhage –Normal is not always as the books describe –Uterine involution Also a bit variable Also a bit variable –Retained products of conception To an extent there are always RPOC To an extent there are always RPOC –The importance of infection It is this that causes symptoms It is this that causes symptoms –The role of ultrasound Only useful when negative Only useful when negative –Management options Should always include BS antibiotics Should always include BS antibiotics Curette gently please! Curette gently please!

Day 3 Boobs and bottoms Boobs and bottoms –Breast engorgement –Nipple issues It’s all about attachment It’s all about attachment And detachment And detachment –Lactation suppression Many options but the safest is nothing Many options but the safest is nothing Anti prolactin agents for stillbirth etc Anti prolactin agents for stillbirth etc –Ectopic breast tissue –Constipation Fruit, fibre and fluids Fruit, fibre and fluids –Haemorrhoids Beware of the cure that is worse than the disease! Beware of the cure that is worse than the disease!

Day 4 – 6 months The “Baby Blues” The “Baby Blues” –Up to 80% of parturients –A combination of insomnia, anxiety, pain and hormonal changes –Manage with sympathy & practical support Postnatal Depression Postnatal Depression –5 – 20% –The patient at risk –Diagnosis –Management Counselling Counselling Antidepressants Antidepressants

Some Less common Problems Thromboembolism Thromboembolism –The patient at risk –Prophylaxis –Diagnosis and treatment Caesarean wound infection Caesarean wound infection Episiotomy breakdown Episiotomy breakdown Mastitis Mastitis Severe puerperal psychosis Severe puerperal psychosis Uterine prolapse Uterine prolapse Puerperal infection Puerperal infection

Risk Factors for Puerperal Sepsis Poor/No antenatal care Poor/No antenatal care Anaemia Anaemia Obesity Obesity Harmful traditional practices Harmful traditional practices Long labour Long labour –Prolonged rupture membranes –Repeated vaginal examinations Chorioamnionitis Chorioamnionitis General anaesthesia General anaesthesia Operative delivery Operative delivery –Emergency Caesarean section –Traumatic vaginal birth PPH and manual removal PPH and manual removal Retained products of conception Retained products of conception

Causes of Puerperal Fever The work of labour The work of labour –Low grade –Settles within hours with rehydration Genital Tract Infection Genital Tract Infection –Endometritis –Lower genital tract infection with trauma/haematoma –Severe puerperal sepsis/Septic shock Urinary Tract Infection Urinary Tract Infection Lung infections and atelactasis Lung infections and atelactasis –Especially after GA Malaria Malaria Other Other –Mastitis –Typhoid –Meningitis etc.

Organisms involved in Genital Tract Sepsis and their Treatment Gram Positives Gram Positives Streptococcus B and A Streptococcus B and A Staphylococcus Staphylococcus Clostridia Clostridia –Treat with Penicillin or Cephalosporin Gram Negatives (the gut organisms) Gram Negatives (the gut organisms) E Coli, Klebsiella, Proteus, Pseudomonas, Salmonella E Coli, Klebsiella, Proteus, Pseudomonas, Salmonella –Treat with “Mycins” e.g. Gentamicin Anaerobics Anaerobics Bacteroides, Streptococi Bacteroides, Streptococi –Treat with Metronidazole Role of vaginal and wound swabs limited Role of vaginal and wound swabs limited Blood culture is the best option Blood culture is the best option

Perineal Wound Breakdown Begin with good perineal hygiene Begin with good perineal hygiene Timely debridement and repair in theatre Timely debridement and repair in theatre Use long-lasting interrupted sutures Use long-lasting interrupted sutures

Mastitis and Breast Abscess Often begins with a ‘flu-like illness characterised by temperatures >40 0 C Often begins with a ‘flu-like illness characterised by temperatures >40 0 C Do not stop breast feeding Do not stop breast feeding –Drain this breast first Usually associated with nipple damage Usually associated with nipple damage –Plus incomplete breast emptying Staphylococcus aureus in the vast majority Staphylococcus aureus in the vast majority –May require Fluocloxacillin –But Erythromcin and any penicillin will often work Only a few should proceed to abscess that requires drainage Only a few should proceed to abscess that requires drainage –Keep the patient out of the hands of surgeons! Recurrent mastitis usually associated with poor breast-feeding technique Recurrent mastitis usually associated with poor breast-feeding technique

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