Changes to a woman after delivery called pueperium

1. NORMAL AND ABNORRMAL
PUERPERIUM
PRESENTED BY BISHAR MUHAMMED OSMAN 4.2

2. NORMAL PUERPERIUM
definition:
 Puerperium is the period following childbirth during
which the body tissues, especially the pelvic organs revert
back approximately to the prepregnant state both
anatomically and physiologically.
 Involution is the process whereby the genital organs revert
back approximately to the state as they were before
pregnancy

3. duration: Puerperium begins as soon as the placenta is
expelled and lasts for approximately 6 weeks when the
uterus becomes regressed almost to the nonpregnant size.
The period is arbitrarily divided into —
(a) immediate – within 24 hours,
(b) early – up to 7 days and
(c) remote – up to 6 weeks.
Similar changes occur following abortion but takes a
shorter period for the involution to complete.

4. Fourth trimester is the time from delivery until complete physiolgical
involution and psychological adjustment
INVOLUTION OF THE UTERUS
anatomical Consideration
Uterus:
 Immediately following delivery, the uterus becomes firm
and retract with alternate hardening and softening. The
uterus measures about 20 × 12 × 7.5 cm3
 At the end of 6 weeks, its measurement is almost similar
to that of the nonpregnant state and weighs about 60 g

5.  Lower uterine segment: Immediately following delivery, the
lower segment becomes a thin, flabby and collapsed
structure.
 It takes a few weeks to revert back to the normal shape and
size of the isthmus, i.e. the part between the body of the
uterus and internal os of the cervix

6. Cervix:
• The cervix contracts slowly; the external os admits
two fingers for a few days but by the end of 1st
week, narrows down to admit the tip of a finger
only.
• However, the external os can remain open permanently,
giving a characteristic appearance to the parous cervix.

7. Physiological Consideration
The physiological process of involution is most marked in the body
of the uterus.
Changes occur in the following components:
(1)Muscles,
(2)(2) Blood vessels,
(3) (3) Endometrium.
(4)Muscles: There is marked hypertrophy and hyperplasia of
muscle fibers during pregnancy and the individual muscle fiber
enlarges to the extent of 10 times in length and 5 times in
breadth.
During puerperium, the number of muscle fibers is not decreased,
but there is substantial reduction of the myometrial cell size.

8. Blood vessels: The changes of the blood vessels are
pronounced at the placental site.
• The arteries are constricted by contraction of its
wall and thickening of the intima followed by
thrombosis.
During the 1st week, arteries undergo thrombosis,
hyalinization and fibrinoid endarteritis

9. Endometrium:
Following delivery, the major part of the decidua is cast off with
the expulsion of the placenta and the membranes, more at the
placental site.
The endometrium left behind varies in thickness from 2 mm to 5
mm
Regeneration of the epithelium startby 7th day and is completed by
10th day and the entire endometrium is restored by the day 16,
except at the placental site where it takes about 6 weeks.

10. Clinical assessment of involution
The rate of involution of the uterus can be assessed
clinically by noting the height of the fundus of the uterus
in relation to the symphysis pubis.
The measurement should be taken carefully at a fixed
time every day, preferably by the same observer
The uterus is to be centralized and with a measuring tape,
the fundal height is measured above the symphysis pubis

11. Following delivery, the fundus lies about 13.5 cm above the
symphysis pubis.
During the first 24 hours, the level remains constant; thereafter,
there is
a steady decrease in height by 1.25 cm in 24 hours, so that by the
end of 2nd week the uterus becomes a pelvic organ.
The rate of involution thereafter slows down until by 6 weeks, the
uterus becomes almost normal in size

12. INVOLUTION OF OTHER PELVIC STRUCTURES
Vagina:
The distensible vagina, noticed soon after birth takes
a long time (6–10 weeks) to involute.
It regains its tone but never to the virginal state.
The mucosa remains delicate for the first few weeks
and submucous venous congestion persists even
longer.
It is the reason to withhold surgery on puerperal
vagina.

13. Broad ligaments and round ligaments require considerable
time to recover from the stretching and laxation.
Pelvic floor and pelvic fascia take a long time to involute
from the stretching effect during parturition
LOCHIA
It is the vaginal discharge for the first fortnight during
puerperium.
The discharge originates from the uterine body, cervix
and vagina.

14. Odor and reaction: It has got a peculiar offensive fishy smell. Its
reaction is alkaline, tending to become acid toward the end.
Color: Depending upon the variation of the color of the discharge, it
is named as:
1)lochia rubra (red) 1–4 days,
(2) lochia serosa (5–9 days) — the color is yellowish or pink or pale
brownish,
(3) lochia alba — (pale white) — 10–15 days.
Composition:
Lochia rubra consists of blood, shreds of fetal membranes and
decidua, vernix caseosa, lanugo and meconium.

15. Lochia serosa consists of less RBC but more leukocytes,
wound exudate, mucus from the cervix and
microorganisms (anaerobic streptococci and
staphylococci).
The presence of bacteria is not pathognomonic unless
associated with clinical signs of sepsis.
Lochia alba contains plenty of decidual cells, leukocytes,
mucus, cholesterin crystals, fatty and granular epithelial
cells and microorganisms

16. amount: The average amount of discharge for the first 5–6 days is
estimated to be 250 mL.
Normal duration:
The normal duration may extend up to 3 weeks. The red lochia may
persist for longer duration especially in women who get up from the
bed for the first time in later period.
The discharge may be scanty, especially following premature labors
or may be excessive in twin delivery or hydramnios.

17. Clinical importance:
The character of the lochial discharge gives useful information about
the abnormal puerperal state.
The vulval pads are to be inspected daily to get information of:
Odor: If malodorous—indicates infection. Retained plug or cotton
piece inside the vagina should be kept in mind.
Amount: Scanty or absent — signifies infection or lochiometra. If
excessive — indicates infection.

18. Color: Persistence of red color beyond the normal
limit signifies subinvolution or retained bits of
conceptus.
Duration: Duration of the lochia alba beyond 3
weeks suggests local genital lesion.

19. GENERAL PHYSIOLOGICAL CHANGES
Pulse:
For a few hours after normal delivery, the pulse
rate is likely to be raised, which settles down to
normal during the second day

20. Temperature: The temperature should not be above
37.2°C (99°F) within the first 24 hours.
There may be slight reactionary rise following delivery by
0.5°F but comes down to normal within 12 hours.
On the 3rd day, there may be slight rise of temperature
due to breast engorgement which should not last for more
than 24 hours.
However, genitourinary tract infection should be excluded
if there is rise of temperature

21. urinary Tract:
The bladder may be overdistended without any desire
to pass urine.
The common urinary problems are: overdistention,
incomplete emptying and presence of residual urine.
Urinary stasis is seen in more than 50% of women.
The risk of urinary tract infection is, therefore, high.
Dilated ureters and renal pelvis return to normal size
within 8 weeks.

22. Gastrointestinal Tract
Increased thirst in early puerperium is due to loss of fluid
during labor, in lochia, diuresis and perspiration.
Constipation is a common problem for the following
reasons:
 delayed gastrointestinal motility
 mild ileus following delivery, together with perineal
discomfort.
Some women may have the problem of anal incontinence.

23. ovarian function (menstruation and ovulation):
The onset of the first menstrual period following
delivery is very variable and depends on lactation.
If woman does not breastfeed her baby,
menstruation returns by 12th week following
delivery in 80% of cases.
The meantime for onset of first menstruation is
7 – 9 weeks.

24. contraceptive protection is about 98% up to 6 months of
postpartum.
Thus, lactation provides a natural method of contraception .
Nonlactating mother should use contraceptive measures in
3rd postpartum week and the lactating mother in 3rd
postpartum month.

26. LACTATION
For the first 2 days following delivery, no further anatomic
changes in the breasts occur.
The secretion from the breasts called colostrum, which
starts during pregnancy becomes more abundant during
the period.

27. In nonlactating mothers, ovulation may occur as
early as 4 weeks and in lactating mothers about
10 weeks after delivery.
Duration of anovulation depends upon the
frequency (>8/24 hours), intensity and duration
of breastfeeding

28. MANAGEMENT OF NORMAL PUERPERIUM
The principles in management are:
(1) To restore the health of the mother.
(2) To prevent infection.
(3) To take care of the breasts, including
promotion of breastfeeding.
(4) To motivate the mother for contraception.

29. IMMEDIATE ATTENTION
immediately following delivery, the patient
should be closely observed as outlined in the
management of the fourth stage of labor

30. Emotional support is essential.
Usually the first feeling of mother is the sense of
happiness and relief, with the birth of a healthy baby.
The woman needs emotional support when she suffers
from postpartum blues or stress due to newborn’s
prematurity, illness, congenital malformation or death.

31. rest and ambulance:
Early ambulation after delivery is beneficial.
After a good resting period, the patient becomes
fresh and can breastfeed the baby or moves out of
bed to go to the toilet. Early ambulation is encouraged

32. Advantages of ambulation:
(1)provides a sense of well-being,
(2)(2) bladder complications and constipation are less,
(3)(3) facilitates uterine drainage and hastens involution of
the uterus and
(4) lessens puerperal venous thrombosis and embolism

33. Care of The Bladder:
The patient is encouraged to pass urine following delivery as soon as
convenient. At times, the patient fails to pass urine and the causes
are —
(1) unaccustomed position
(2) reflex pain from the perineal injuries.
This is common after a difficult labor or a forceps delivery.
If the patient still fails to pass urine, catheterization should be done

34. Catheterization is also indicated in case of incomplete
emptying of the bladder evidenced by the presence of
residual urine of more than 60 mL.
Continuous drainage is kept until the bladder tone is
regained.
The underlying principle of the bladder care is to ensure
adequate drainage of urine so that infection and cystitis are
avoided

35. MANAGEMENT OF AILMENTS
After pain — It is infrequent, spasmodic pain felt in
the lower abdomen after delivery for a variable
period of 2–4 days.
Presence of blood clots or bits of after births lead to
hypertonic contractions of the uterus in an attempt
to expel them out

36. The treatment includes massaging the uterus with
expulsion of the clot followed by administration of
analgesics (Ibuprofen) and antispasmodics
Correction of anemia: Majority of the women in the tropics
remain in an anemic state following delivery.
Supplementary iron therapy (ferrous sulfate 200 mg) is to be
given daily for a minimum period of 4–6 weeks

37. Hypertension is to be treated until it comes
to a normal limit. Physician should be
consulted if proteinuria persists

38. Complications during puerperium
(a) Immediate—
(b)(1) Postpartum hemorrhage, (2) Shock—hypovolemic,
endotoxic or idiopathic,
(3) Postpartum eclampsia, (4) Pulmonary embolism—liquor
amnii or air, (5) Inversion.
(b) Early (within one week)—(1) Acute retention of urine, (2)
Urinary tract infection, (3) Puerperal sepsis, (4) Breast
engorgement, (5) Mastitis and breast abscess, (6) Pulmonary
infection (atelectasis),

39. 7) Anuria following abruptio placentae, mismatched blood
transfusion or eclampsia.
(c) Delayed—(1) Secondary postpartum hemorrhage, (2)
Thromboembolic manifestation— pulmonary embolism,
thrombophlebitis, (3) Psychosis, (4) Postpartum
cardiomyopathy, (5) Postpartum hemolytic uremic syndrome

40. Abnormalities of the Puerperium
 Puerperial Pyrexia
 Puerperial sepsis
 Subinvolution
 Urinary complication
 Breast complication
 Puerperial venous thrombosis
 Psychiatric disorders

41. A rise of temperature reaching 100.4°F (38°C) or more
(measured orally) on two separate occasions at 24 hours
apart (excluding first 24 hours) within first 10 days
following delivery is called puerperal pyrexia
Puerperal Pyrexia

42. Causes of Puerperal Pyrexia
• Puerperal sepsis
• Urinary tract infections: Cystitis, Pyelonephritis
• Mastitis, Breast abscess
• Wound infections: CS or Episiotomy
• Pulmonary infections : Atelectasis, Pneumonia
• Septic pelvic thrombophlebitis
• A recrudescence of malaria or pulmonary tuberculosis
• Others: Pharyngitis, Gastroenteritis

43. Puerperal Sepsis ( Puerperal
infection)
definition: An infection of the genital tract at any time
between delivery of foetus till 42days after delivery is
puerperial sepsis
There has been marked decline in puerperal sepsis
during the past few years due to: (1) improved
obstetric care, (2) availability of wider range of
antibiotics.

44. Puerperal sepsis is commonly due to—
(i) endometritis,
(ii) endomyometritis, or
(iii) endoparametritis or a combination of all these when
it is called pelvic cellulitis.

45. Predisposing factors of Puerperal sepsis
Antepartum risk factors,
(1) Malnutrition and anemia,
(2) Preterm labor,
(3) Premature rupture of the membranes,
(4) Immunocompromised (HIV),
(5) Prolonged rupture of membrane more than
18 hours,
(6) Diabetes.
Frequent vaginal examinations

46. Intrapartum risk factors:
(1) Repeated vaginal examinations,
(2) Dehydration and ketoacidosis during labor,
(3) Traumatic vaginal delivery,
(4) Hemorrhage—antepartum or postpartum,
(5) Retained bits of placental tissue or membranes,
(6) Prolonged labor,
(7) Obstructed labor,
(8) Cesarean delivery

47. Microorganisms responsible for puerperal sepsis and the major
pathology
Aerobic—Group A beta-hemolytic Streptococcus (GAS),Group B beta-
hemolytic Streptococcus (GBS) Staphylococcus pyogenes, S. aureus, E.
coli, Klebsiella, Pseudomonas, Proteus, Chlamydia.
Anaerobic—Streptococcus, Peptococcus, Bacteroides (fragilis, bivius),
Fusobacteria, Mobiluncus and Clostridia
Most of the infections in the genital tract are polymicrobial with a
mixture of aerobic and anaerobic organisms.

48. The primary sites of infection are:
(1) perineum,
(2) vagina,
(3) cervix,
(4) uterus.
The infection is either localized to the site or spreads to
distant sites.
The lacerations on the perineum, vagina and the cervix
are often infected by the organisms due to the presence
of blood clots or dead space

50. Investigations
History and clinical examination
High vaginal endocervical swab
Blood examination
Pelvic ultrasound
..abscess..retained tissues
CT SCAN MRI..

52. treatment
General care:
(i) Isolation of the patient is preferred especially when hemolytic
Streptococcus is obtained on culture,
(ii) Adequate fluid and calorie are maintained by intravenous
infusion (IV),
(iii) Anemia is corrected by oral iron or if needed by blood
transfusion,
(iv) An indwelling catheter is used to relieve any urine retention
due to pelvic abscess

53. Antibiotics
Ideal antibiotic regimen should depend on the culture and
sensitivity report.
Pending the report, gentamicin (2 mg/kg IV loading dose, followed
by 1.5 mg/kg IV every 8 hours) and clindamycin (900 mg IV every 8
hours) should be started.
Metronidazole 0.5 g IV is given at 8 hours interval to control the
anaerobic group
The treatment is continued until the infection is controlled for at
least 7–10 days.

54. Subinvolution
definition:
When the involution is impaired or retarded, it is called
subinvolution.
The uterus is the most common organ affected in
subinvolution.
As it is the most accessible organ to be measured per
abdomen, the uterine involution is considered clinically as
an index to assess subinvolution.

55. Causes:
Predisposing factors are—
(1)Grand multiparity,
(2) Overdistension of uterus as in twins and hydramnios,
(3) Maternal ill-health,
(4)Cesarean section,
(5) Prolapse of the uterus,
(6) Retroversion after the uterus becomes pelvic organ,
(7) Uterine fibroid.
Aggrevating factors
Retained product of conception
Uterine sepsis(endometritis)

56. symptoms:
The condition may be asymptomatic. The
predominant symptoms are:
(1) abnormal lochial discharge, either excessive or
prolonged, (2) irregular or at times excessive uterine
bleeding,
(3) irregular cramp-like pain in cases of retained
products or rise of temperature in sepsis

57. Management
Mere size of the uterus is not important and provided there
is absence of features, such as excessive lochia or irregular
bleeding or sepsis, the size of the uterus can be safely
ignored.
Appropriate therapy is to be instituted only when
subinvolution is found to be a mere sign of some local
pathology:
(1) Antibiotics in endometritis,
(2) Exploration of the uterus in retained products
 Methargin to enhance involution process
 Pessary in prolapse or retroversion

58. Urinary complications in pregnancy
urinary tract infection: It is one of the common causes of
puerperal pyrexia, the incidence being 1–5% of all deliveries.
The infection may be the consequence of any of the
following:
(1) Recurrence of previous cystitis or pyelitis, (2)
Asymptomatic bacteriuria becomes overt, (3) Infection
contracted for the first time during puerperium

59. retention of urine:
This is a common complication in early
puerperium. The causes are—
(1) Bruising and edema of the bladder neck,
(2) Reflex from the perineal injury,
(3) (3) Unaccustomed position.

60. Treatment: If simple measure fails to initiate
micturition, an indwelling catheter is to be kept in
situ for about 48 hours.
This not only empties the bladder but helps in
regaining the normal bladder tone and sensation
of fullness

61. Breast Complications
the common breast complications in puerperium are:
(1) breast engorgement,
(2) cracked and retracted nipple leading to difficulty in
breastfeeding,
(3) mastitis and breast abscess,
(4) lactation failure. Breast engorgement and infection
are responsible for puerperal pyrexia.

62. • Breast engorgement is due to exaggerated
normal venous and lymphatic engorgement of
the breasts which precedes lactation.
• This in turn prevents escape of milk from the
lacteal system
Breast engorgement

63. Onset: It usually manifests after the milk secretion starts (third or
fourth day postpartum).
Symptoms include—
(a) Considerable pain and feeling of tenseness or heaviness in
both the breasts,
(b) Generalized malaise or even transient rise of temperature
and
(c) Painful breastfeeding.

64. Treatment:
(1) To support the breasts with a binder or brassiere,
(2) Frequent suckling,
(3) Manual expression of any remaining milk after each feed,
(4) To administer analgesics for pain
,
(5) The baby should be put to the breast regularly at frequent
intervals,
(6) In a severe case, gentle use of a breast pump may be
helpful.

65. Cracked and retracted nipple
The nipple may become painful due to—
(1) Loss of surface epithelium with the formation of a raw area on
the nipple,
(2) or Due to a fissure situated either at the tip or the base of the
nipple.
These two conditions frequently coexist and are referred to as
cracked nipple.

66. it is caused by—
(a) unclean hygiene resulting in formation of a crust over the
nipple,
(b) retracted nipple, and
(c) trauma from baby’s mouth due to incorrect attachment
to the breast,
(d) infection with Candida albicans and
S. aureus is often present
Treatment: Correct attachment (latch on) will provide
immediate relief from pain and rapid healing

67. acute mastitis
the incidence of mastitis is 2–5% in lactating and less than 1%
in non-lactating women.
The common organisms involved are S. aureus, Staphylococcus
epidermidis and Streptococci viridans.
Risk factors for mastitis are poor nursing, maternal fatigue and
cracked nipple

68. Clinical features:
Symptoms include—(a) Generalized malaise and headache,
nausea, vomiting, (b) Fever (102°F or more) with chills, and
(c) Severe pain and tender swelling in one quadrant of the
breast.
Signs include—(a) Presence of toxic features, and (b)
Presence of a swelling on the breast. The overlying skin is
red, hot and flushed and feels tense and tender

70. Management—
(a) Breast support,
(b) Plenty of oral fluids,
(c) Breastfeeding is continued with good
attachment. Nursing is initiated on the uninfected
side first to establish let down,
(d) The infected side is emptied manually with each
feed,

71. Dicloxacillin (penicillinase-resistant penicillin) is the drug of
choice. A dose of 500 mg every 6 hours orally is started till the
sensitivity report available. Erythromycin is an alternative to
patients who are allergic to penicillin. Antibiotic therapy is
continued for at least
7 days,
(f) Analgesics (ibuprofen) are given for pain,
(g) Milk flow is maintained by breastfeeding the infant.

72. Puerperal venous thrombosis and Pulmonary
embolism
thrombosis of the leg veins and pelvic veins is one of the
common and important complications in puerperium
especially in the Western countries.
The prevalence is, however, low in Asian and African countries.

73. The important signs and symptoms of pulmonary
embolism are:
tachypnea (>20 breaths/min),
dyspnea,
pleuritic chest pain,
cough, tachycardia (>100 bpm),
hemoptysis and rise in temperature more than 37°C.

74. Psychiatric disorders during pregnnacy
Puerperal Blues
It is a transient state of mental illness observed 4–5 days after
delivery and it lasts for a few days.
Nearly 50% of the postpartum women suffer from the problem.
Manifestations are—depression, anxiety, tearfulness, insomnia,
helplessness and negative feelings toward the infant
Treatment is reassurance and psychological support by the family
members

75. Postpartum psychosis (schizophrenia)
Observed in about 0.14–0.26% of mothers. Commonly seen in
women with past history of psychosis or with a positive family
history.
Onset is relatively sudden usually within 4 days of
delivery
Management: A psychiatrist must be consulted urgently.
Hospitalization is needed. Chlorpromazine 150 mg stat and 50–150 mg
three times a day is started. Sublingual estradiol (1 mg thrice daily)
results in significant improvement

76. Thanks to all