Anatomic and physiologic changes

during postpartum:

1. Uterine Involution
2. Return of Menstruation
3. Vagina
4. Cardiovascular System
Normal Puerperium

Definition

It is the period following delivery of the baby and

placenta to 6 weeks postpartum.

It is the period during it ,the reproductive

organs & maternal physiology returns towards the
pre pregnancy state .
(1) Uterine Involution

* it rapidly decreases in weight from 1000 g - 100 g

in the first 3 weeks postpartum.

* lochia
=lochia ruba: bloody discharge in the first few
days after delivery.
=lochia serosa: the discharge becomes pale in
color after 3 – 4 days.
=lochia alba: uterine discharge assumes a
white or yellow-white color by
the 10th day postpartum.
NB:
foul-smelling lochia suggests endometritis.
(2) Return of menstruation
* non-nursing mothers:
menstruation returns by 6 – 8 weeks.

* nursing mothers:
may develop lactating amenorrhea.

NB:
In all women , although ovulation may not occur
for several months ,particularly in nursing mothers
contraceptive use should be advised during the
puerperium to avoid an undesired pregnancy.
(3) Vagina
* the supportive tissues of the pelvic floor
gradually returns its former tone.
* women who deliver vaginally should be
taught & encouraged to perform Kegel excercises

(4) Cardiovascular system

* cardiac output & plasma volume gradually
returns to normal during the first 2 weeks.
* marked weight loss occurs in the first week
as a result of the decrease of plasma volume
and the deuresis of the extracellular fluid.
(4) Breastfeeding

Correct Wrong
* Complications
1. Fissured Nipples:
= nipples may become fissured and nursing
become painful and difficult.
= breast fissures are a portal of entry for
bacteria, so they should be managed aggressively
by lanolin breast cream.
= further breast feeding should be stopped , milk
can be expressed manually until the nipples
heal and breastfeeding can be resumed.
2. Mastitis :
= uncommon complication usually develops
after 2 – 4 weeks.
= symptoms & signs
low grade fever , chills , indurated ,red and painful
segment of the breast.
= caused by Staphylococcus aureus bacteria
from the infant’s oral pharynx.
= mother should start antibiotics immediately,
such as dicloxacillin for 7-10 days.

= breastfeeding may be discontinued so, breast

pump can be used to maintain lactation .
however , suppression of lactation is advisable.

= if a breast abscess develops , it should be

surgically drained.
Breast
abscess
3. Drug passage to the newborn:

= infant ingest up to 500 ml of breast milk /day.

thus , maternally administrated drugs that
pass to breast milk may have significant effect.

= amount of drug in breast milk depends on:

* maternal drug dose.
* rate of maternal clearance.
* physiochemical properties of the drug.
* composition of the breast milk with respect to
fat and protein.
* infant GA at birth.
 Abnormal Puerperium

Puerperal Disorders:

1. Puerperal Pyrexia.
2. 2ry Postpartum Hemorrhage.
3. Thromboembolism.

4. Perineal Complications.
5. Bladder Dysfunction.
6. Bowel Dysfunction.
Puerperal Pyrexia

Definition:
a temperature of 38C or > lasts for 2 days
or > in the first 10 days postpartum,
exclusive of the first 24h.

Fever during puerperium must be regarded as

result in from genital tract infection

(puerperal sepsis)

until prove otherwise.

 Causes:

1. genital tract infection ( puerperal sepsis ).

2. milk engorgement ,mastitis & breast abscess
3. DVT (Deep Vein Thrombosis) & PE (Pre Eclampsia).

4. UTI.
5. chest infection.
6. CS delivery, wound infection & fasciites.
7. meningitis.
 Genital Tract Infection
( Puerperal Sepsis)

Incidence: 3%
7% of all direct maternal deaths , excluding deaths
after abortion.

Etiology:
Puerperal infection is usually poly microbial
involves contaminants from the bowel
that colonize the perineum and
lower genital tract.
The most frequently identified organisms are :

* Group B Streptococcus.
* Mycoplasma species.
* others:
=Gram +ve
-beta-hemolytic streptococcus gr.A,B,D
-staphylococcus aureus.
-staphylococcus faecalis.
=Gram –ve
-E coli
-Hemophilus influenzae.
-gardenella vaginalis.
=Anaerobes
as; Bactroides fragilis.
=Miscellaneous
as; Chlamydia trachomatis
Predisposing Factors:

1. manual removal of the placenta.

2. placental separation exposes a large raw area.
3. retained products of conception & blood clots.
4. CS wound ,episiotomy and genital tract
lacerations.
Risk Factors

1. instrumental delivery.
2. internal fetal monitoring.
3. multiple vaginal examinations.
4. prolonged ROM and chorioamnonitis.
5. cervical cerclage.

6. Non obstetric :
.. Obesity.
.. DM.
.. HIV.
Factors that determine
the clinical course & severity of the infection:

1. general health and resistance of the woman.

2. virulence of the causative organisms.

3. presence of predisposing factors as bl. Clots,

hematoma or retained products of conception.

4. timing of antibiotic therapy.

Diagnosis
A. Clinical Picture
symptoms:
• fever ,rigors, malaise, headache.
• vomiting and diarrhoea.
• abdominal discomfort.
• offensive lochia.
• 2ry PP haemorrhage.
signs:
• pyrexia and tachycardia.
• uterus is large and tender.

• infected wounds as CS or perineal lacerations

• peritonism and paralytic ileus (severe cases).

• indurated adnexae due to parametritis.
• fullness in pelvis due to abscess.
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Investigations:

1. FBC anaemia, leukocytosis ,

thrombocytopenia.
2. Coagulation Profile DIC.
3. RFT & Electrolytes fluid & electrolytes
imbalance.
4. Arterial blood gas acidosis & hypoxia.
( septiceamic shock)
5. High vaginal swabs infection.
and blood cultures.
6. Pelvic US :
=retained products = adnexal mass
=pelvic abscess.
Prevention:
1. awareness of general hygiene principles.

2. good surgical technique with proper hemostasis.

3. prophylactic antibiotics
especially in emergency CS.
a single intra operative dose of cephalosporin+
metronidazole.
Treatment
A. Mild and Moderate infections :
broad spectrum antibiotic as:
cephalosporin + metronidazole.
in the first 48h ,antibiotic should be given IV.

B. Severe infections :
septic/endotoxic shock
appropriate antibiotics should be aggressively
given ,any delay could be fatal.
Complications

1. Pelvic abscess
salpingo- ophoritis and pelvic peritonitis . This
could progress to a generalized peritonitis and
the development of pelvic absess.

2. Pelvic Peritonitis
metritis and parametitis.

3. Septic Thrombophlebitis
spread to distant sites via lymphatics to
the iliac vessels or directly via the ovarian
vessels.
Necrotizing Fasciitis

* fatal infection of skin ,fascia and muscle. It occurs

in the perineal tears, episiotomy sites & CS
wounds.
* caused by a variety of bacteria including
anaerobes.

* in addition to signs of infection ,there is extensive

necrosis which is managed by surgical removal of
the necrotic tissue under general anesthesia and
split-thickness skin grafts. This is essential to
avoid mortality.
(2) Secondary Postpartum Hemorrhage

* it is fresh bleeding from the genital tract after

the first 24 h. till 6 weeks after delivery.
(7 – 14 days).

* the most common cause is retained placental

reminants. Endometritis is another cause. Then
bleeding disorders ,hormonal contraception and
choriocarcinoma.
* associated features are cramps abdominal pain.
the uterus is larger than expected and signs of
infection as tenderness .
* Management
* Diagnosis :
US is mandatory.
* Treatment :
= IV blood transfusion.
= Syntocinon infusion.
= Antibiotics
should be given if placental tissues are found
even without evidence of overt infection.
= evacuation of the uterus under general
anesthesia .
(3) Perineal Complications
1.perineal discomfort
* it is the single major problem for mothers in
the first 3 days .
* discomfort is greatest in the presence of
episiotomy ,spontaneous tears following
instrumental delivery.
* treatment
• local cooling by crushed ice.
• topical anaesthetics as 5% lignocaine gel.
• analgesics ; paracetamol or NSAIDs as;
diclofenac suppositories at delivery
followed by another 12h latter.
 2. perineal infection
* uncommon , but if signs of infection occur
these must be taken seriously.
* caused by bacterial contamination during
delivery ,thus swabs from infected wounds
for culture & antibiotic sensitivity.

* treatment
..antibiotics.
..drainage if pus collected by removal of
any skin sutures.
..if spontaneous opening of repaired tears
or episiotomy ,in presence of infection,
should be irrigated twice daily & healing
is allowed by secondary intention.
(4) Bladder Dysfunction

* Voiding difficulty and over-distention of the

bladder are not uncommon after delivery ,
especially ,if epidural or spinal anesthesia
has been used.

* Causes
• after epidural anesthesia the bladder may
take 8 – 12h to regain normal sensation.

During this time about 1 liter of urine is

produced and therefore ,urinary retention
occurs.
 • caused also by pain or peri urethral edema
due to traumatic delivery as :
instrumental delivery , multiple extended
lacerations ,vulvo vaginal hematomas .

* Distended bladder is diagnosed by being

palpated as a suprapubic cystic mass or it may
displace the uterus upwards or laterally , so
increasing the height of the uterine fundus.
* treatment
if regional anesthesia has been used ,urinary
catheter should be left in situ for the first
12 – 24h especially if the residual urine in the
bladder is > 300 ml.

* Important
stress incontinence is a rare problem in the
puerperium ,thus any urine incontinence
should be investigated to exclude obstetric
fistulae.
(5) Bowel Dysfunction

* Constipation is a common problem in the

puerperium. It caused either by interruption
in the normal diet and dehydration during
labor or as a result of fear of evacuation due
to pain from a sutured perineum.

* Advice on adequate fluid & fiber intake is

necessary.
* In repaired 3rd and 4th degree perineal tears,
avoidance of constipation & straining is very
important as it would disrupt the repaired anal
sphincter and cause anal incontinence.

* It is important to give Lactulose and fibers as;

Regulan immediately after repair for 2 weeks.
* Long -term anal incontinence following repair
of 3rd and 4th degree perineal tears occurs in
5% and recto-vaginal fistula in 3% in the
postpatum period.

* Occult anal sphincter trauma occurs in 10-30%

of primiparous women , due to disruption of
the internal anal sphincter detected by
trans anal US.
Thromboembolic Disorders
 Blood clot formed from impeded blood flow
 Causes
 Hypercoagulability of blood
 Venous stasis
 Injury to epithelium of vessels
 Increased risk
 Prevention
 Avoid dehydration
 Avoid trauma to legs in stirrups
 Early postpartum ambulation
 Leg exercises to support venous return
 No smoking
 Antiembolism stockings
Thromboembolic
Disorders

 Superficial thrombophlebitis
 3 to 4th day after delivery

 Assessment
 Tenderness >> Localized heat
 Swelling >> Redness
 No or low fever
 Intervention
 Elevate leg >> Bed rest
 Local moist heat >> Analgesia
 Little risk of pulmonary embolism
Thromboembolic
Disorders
 Deep vein thrombosis
 10 to 20 days after delivery
 Assessment
 Swelling
 Pain

 Erythema
 Heat

 Pedal edema
 Low to high fever
 Positive Homan’s

 Chills
Thromboembolic
Disorders
 Deep vein thrombosis
 Intervention
 Bed rest >> Elevate leg
 Analgesia >> Antibiotics
 Anticoagulant therapy

 IV heparin

 Coumadin for 2 to 6 months

 Monitor for pulmonary embolism

 Antiembolism stockings after symptoms:

Thromboembolic
Disorders
 Pulmonary embolism
 Clot moves to pulmonary artery
 Assessment
 Dyspnea >> Chest pain
 Cough >> Hemoptysis
 Cyanosis >> Hypotension
 Tachypnea >> Tachycardia
 Treatment
 Alert physician >> Elevate head of bed
 Oxygen >> Narcotics
 Anticoagulation with heparin
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