1. Normal and Abnormal Puerperium
Assoc. Prof. Gazi YILDIRIM

2. 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.

3. Normal Puerperium
The relevant anatomy and physiology in the puerperium
Reproductive organs
Uterus
1000g → g
The endometrial lining rapidly regenerates (16 days)
The placental site undergoes a series of changes in the postpartum period

4. 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.

5. 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

6. 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 (the first 2-4 days)
The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

7. 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

8. 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 :

9. 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.

11. 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.

13. Management of normal puerperium
4 ) - Early mobilization.
5 ) - Management of episiotomy ;and perennial tears.
6 ) -In normal delivery the mother can go home 48 hours after delivery ;and 10 days in C.S.
7 ) - Diet regime.
8 ) - postnatal visit.
9 ) - Advising for contraception and spacing of pregnancy.

14. breast feeding

16. 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.

17. Puerperal Infection Risk factors PROM Anemia Hemorrhage EP and CS
Placenta retain

18. Puerperal Infection Common pathogens Aerobes
Group A, B, and D streptococci
Gram-negative bacteria: Escherichia coli, Klebsiella
Staphylococcus aureus

19. Puerperal Infection Anaerobes Petococcus species
Petostreptococcus species
Bacteroides fragilis group
Clostridium species
Other
Chlamydia trachomatis
Mycoplasma species

20. Puerperal Infection Manifestation
Acute vulvitis vaginitis and cervicitis
Uterine infection
Adnexal infections
Septic pelvic thrombophlebitis
Sapremia

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

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

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

24. END