puerperium is an important stage in woman's reproductive life, it gets its importance as it influences the parturient and the newborn

1. The Puerperium
normal and abnormal
Osama M Warda MD
Professor of obstetrics & Gynecology

2. The definition
 Puerperium: is the period of 6-8 weeks
following the delivery of the fetus and
placenta.
 It is the period taken for the uterus and
other body systems return to the pre-pregnant
condition. Also lactation is initiated
during this period.
 Many changes do occur within the first 2
weeks of puerperium.
O Warda 2

3. Endocrine changes
 Removal of the placenta affects the
physiological state; rapid clearance of
hormones from the placenta and
extra-cellular fluid.
 HPL------disappears from serum by 1-
2 days
 hCG------detected in serum for 2
weeks
 AFP------disappears after several
weeks
O Warda 3
 High levels of E & P ------rapid loss

4. Endocrine changes
cont.,
 Ovulation function-----low for 2 weeks.
 FSH/LH ----suppressed during
pregnancy remain low for 2 weeks
following birth, both in lactating and
non lactating women, however,
gradual increase occurs over 6 weeks.
 The puerperium can be considered a
period of “natural infertility”
O Warda 4

5. Placental site
 Dramatic decrease in size brings
uterine walls into close apposition and
transforms uterus into hard globular
mass.
 This has the effect of applying
pressure on the placental site-----
prevents bleeding.
 Diameter from 18 cm---to 9 cm
 Promoted by continuous action of
pitocin.
O Warda 5

6. Uterine involution
 Immediately after birth the uterine
weight is 1000 grams.
 By day 5 uterus is 500grams
 At the end of puerperium, it is 50-60
grams, and no longer palpable
abdominally.
 Uterine involution may be due to
withdrawal of placental hormones.
O Warda 6

7. Uterine involution cont’d.
 Uterine involution occurs due to 3
processes:
1. Ischemia: occurs as a result of collapse
of blood vessels.
2. Autolysis: is a physiological process by
which involution of the uterus is
achieved. Breakdown of the intracellular
protein by proteolytic & hydrolytic
enzymes.
3. Phagocytosis: disposes of elastic
/fibrous tissue.
O Warda 7

8. O Warda 8

9. The Endometrium
 Regeneration begin 1-2 days after
childbirth.
 Differentiation into 2 layers :
1. Superficial : barrier to infection
2. Basal : source for regeneration
 Regeneration takes about 2-3 weeks.
Placenta site regenerates slowly over
6-7 weeks
O Warda 9

10. Lochia
 It is a characteristic postnatal discharge
that reflects the process of involution and
restoration of the endometrium.
 Mean duration 21-33days; shorter in
multipara and with small babies.
 It runs in 3 stages:
1. Lochia rubra: fresh blood from placenta
2. Lochia serosa: brownish pink after 4 days
3. Lochia alba: whitish discharge.
O Warda 10

11. Cervix and vagina
(after vaginal delivery)
 Cervix is bruised, swollen ,
edematous, and little tone
 By end of 1st week cervix decreased in
size , and closed by the end of 2nd
week.
 Vagina is smooth, edematous, pouting
& bluish.
 Vaginal rugae appear after 3-4 weeks.
O Warda 11

12. Cardiovascular Changes
 Following birth dramatic changes in
hemodilution  cardiovascular instability.
 Cardiac output elevated for 1-2 hours after
birth . Begins to stabilise after about 10
min. Decreases until 10th day. Normal by 2
weeks.
 Cardiovascular system reverts to normal in
2 - 4 weeks.
 Days 2 -5 diuresis dissipates the extra
cellular fluid, up to 3 Kg weight loss.
O Warda 12

13. Coagulation system
 Profound physiological changes in the
blood and dramatic changes in
coagulation and hemostatic
mechanisms.
 Changes protect women from
hemorrhage.
 Levels remain high for 10 days
 DVT/PE – increased risk if trauma,
sepsis, immobility O Warda 13

14. Blood volume changes
 Decreases rapidly over 24 hours.
Increase in hemoconcentration,
hemoglobin rises.
 By 6-9 weeks returned to normal.
O Warda 14

15. Urinary tract
 24-48 hours rapid diuresis –> decreases
plasma volume of blood to non-pregnant
levels.
 High estrogen augments effects of ADH
- increases blood volume
 Larger quantities of nitrogen from
autolysis
 Trauma to bladder base, edema
O Warda 15

16. Post-natal visits: aims
 To provide sound family planning
information and advice
 To care for and monitor the progress of
the mother in the postnatal period and to
give all necessary advice to the mother
on infant care to enable her to ensure
the optimum progress of the newborn
infant
 To examine and care for the newborn
infant; to take all initiatives which are
necessary in case of need and to carry
out immediate resuscitation
O Warda 16

17. ABNORMAL PUERPERIUM
1. PUERPERAL PYREXIA
2. POSTPARTUM HEMORRHAGE
3. PUERPERAL SEPSIS
4. URINARY TRACT PROBLEMS
5. THROMBOEMBOLISM
6. PSYCHIATRIC PROBLEMS
7. OTHERS: a) bowel problems,
b) musculo-skeletal problems,
O Warda 17

18. Puerperal Pyrexia
 A temperature of 38.0°C or higher, which occurs
on any 2 of the first 10 days postpartum,
exclusive of the first 24 hours, and which is taken
orally by a standard technique at least four times
daily. (Joint Committee on Maternal Welfare)
 Some common sites of infection causing
puerpural pyrexia
– Chest
– Throat
– Breasts
– Urinary tract
– Pelvic organs
– Wounds – cesarean, perineal
O Warda 18

19. Puerperal Pyrexia cont.
19
CAUSE DESCRIPTION
Genital tract infection -Tender bulky uterus.
-Prolonged bleeding/pink or discoloured lochia.
-Painful inflamed perineum.
-Most common infective organisms; Escherichia coli, Group A
streptococcus spp., Staphylococcus spp.
Urinary tract infection -Frequency in micturation, painful micturation, haematuria.
-Rigors seen in cases of pyelonephritis
-Most common infective organisms; Escherichia coli, Proteus
spp. and Klebsiella spp.
Mastitis -Painful, hard, red breast abscess
-Nipple trauma and cellulitis
-Most common infective organism; Staphylococcus spp
Postoperative infection
(following Cesarean
section)
-high risk of postpartum septicaemia, wound problems and
fever
-Usual presentation; Painful, red suture line, tenderness on
deep palpation, lochia pink/coloured.
Deep venous thrombosis -Caused by venous stasis.
-Painful, swollen calf.
O Warda
Others -Viral infection or chest infection.

20. Puerperal pyrexia cont.
 Causative organisms
1– Aerobic organisms include beta-hemolytic
streptococci, Escherichia coli,
Klebsiella, Proteus mirabilis,
Pseudomonas, Staphylococcus aureus,
and Neisseria.
2– Anaerobic organisms include
Bacteroides, Peptostreptococcus,
Peptococcus, and Clostridium
perfringens.
O Warda 20

21. Puerperal Pyrexia;
management
 Full examination of chest, breasts,
legs, lochia and bimanual vaginal
examination should be done.
 Majority of infections originate from
the urinary or genital tract.
 Caused by poor sterile technique,
delivery with significant manipulation,
cesarean birth, or overgrowth of local
flora.
O Warda 21

22. Post-partum hemorrhage
 Primary PPH is defined as bleeding from
the genital tract of 600 ml or more in the
first 24 hours following delivery. Such
bleeding usually occurs very
unexpectedly due to retained placental
tissue or birth canal trauma.
 Secondary PPH - bleeding occurs after the
first 24 hours of delivery until the end of
the puerperium.
O Warda 22

23. 23
Type Timescale Presentation Predisposing
factors
Primary
haemorrhage
In the first 24
hours
Fresh bleeding, often
severely
heavy. Uterus may be soft
and
poorly contracted with the
fundus still above the
umbilicus
Uterine atony [90%]
Trauma, vaginal or
cervical
lacerations, labial
tears
Coagulation
disorders
Secondary
haemorrhage
After 24 hours
and up to 6
weeks
May be fresh loss or old,
altered blood, often
malodorous. The
uterus may feel soft, poorly
contracted and possibly
tender,
with the cervical os open
Retained products
of
conception
Endometritis
Dysfunctional
bleeding
O Warda

24. Puerperal Sepsis
 It is a fibrile changes occurring during
puerperium due to invasion of genital tract
by pathogenic bacteria.
Sites of infection:
 Wound: mainly the placental site and
wounds of the perineum, vulva, vagina or
cervix.
Dead tissue: usually blood clots, and
retained placental fragment.
Predisposing factors:
 General: as anaemia, ante partum
hemorrhage, post partum hemorrhage,
malnutrition and toxaemia.
 Local: as lacerations, sloughing and
premature rupture of the mO Weardma brane. 24

25. Puerperal sepsis cont.,
Signs and Symptoms:
 Headache,
 Raised temperature,
 Vomiting,
 Dry tongue and lips.
 Abdominal examination revealed a supra pubic
tenderness and rigidity. The perineum, vulva,
vagina or cervix are become infected and lochia is
foul smelling.
Treatment:
 The primary goal of treatment is concerning the
causes and its predisposing factors for the infection.
 At this time lactation and physiotherapy
program should be stopped until fever
disappear. O Warda 25

26. Urinary tract problems
1- Urinary retention or voiding difficulties: may
occur postnatally secondary to painful tears
involving the bladder or use of epidurals in labor.
 Retention occurs usually immediately after delivery
and is partially due to the sudden decrease in intra
abdominal pressure: –> there is a decreased
stretch reflex response following bladder filling.
 Methods that can encourage micturation
–early ambulation
–pelvic floor exercises
–hot baths
O Warda 26

27. Urinary tract problems cont.
 True incontinence occurs rarely but is
usually associated with a vesico-vaginal
fistula
 After surgical repair, the patient is to
undergo physiotherapy to strengthen
the pelvic floor muscles.
O Warda 27

28. Thrombo-embolism
 Risk of thromboembolism rises 5 fold during
pregnancy & puerperium
 Majority of deaths occur in the puerperium
 The symptoms and signs of venous
thromboembolism:
– leg pain and swelling (usually unilateral)
– lower abdominal pain – low-grade
pyrexia
– dyspnoea – chest pain – hemoptysis
– Calf muscles are tender and painful on firm
palpation.
 If DVT & pulmonary embolism is suspected >>>
– bilateral venogram and/or lung scan should be
carried out within 24-48 hrs.
– full anti-coagulant therapy (heparin) should be
started immediately.
O Warda 28

29. Psychiatric Problems
 Divided into three conditions based on
their severity
1–”Baby blues”
2–Postpartum depression
3–Postpartum psychosis (most severe,
may result in suicide/infanticide)
 A syndrome seen among fathers is
linked to the mood changes of their
wives. May be due to the added
responsibility of having a child and
decreased attention from the wife.
O Warda 29

30. Psychiatric problems;
manage.
1-Postpartum blues: no specific treatment
other than support and reassurance from
family members and friends.
2–Postpartum depression: exclude medical
causes (eg. thyroid dysfunction),
individual/group psychotherapy for mild
cases, medication (antidepressants)/
hospitalization/ electro-convulsive therapy for
moderate to severe cases.
3–Postpartum psychosis: Inpatient treatment
with medication (mood stabilizers-eg.
lithium/valproic acid) and/or electroconvulsive
therapy.
O Warda 30

31. O Warda 31

32. Other Problems
 Bowel problems:
- Haemorrhoids are a common
problem after childbirth, exacerbated
by bearing down during the second
stage of labor.
–Treatment: Local application of 5%
lidocaine gel or anusol
(hydrocortisone) cream together with
bulking agents (eg. Psyllium, fiber) to
soften the motions.
O Warda 32

33. Other problems
 Musculo-skeletal problems:
1– Painless divarication (spreading
apart) of the recti: can occur
antenatally due to the enlarging uterus
that exerts pressure on the recti,
causing them to separate.
– Treatment involves
exercises that increase
muscle tone.
O Warda 33

34. Other problems
 Musculo-skeletal problems:
2- pelvic joints pain:
- In pregnancy the pelvic ligaments become
more lax and the symphysis pubis will
separate to some extent. This is beneficial
as the anterior-posterior diameter is
increased.
–In extreme situations the hemi-pelvices
can be widely separated causing severe
pain making walking difficult.
–Treatment: Milder cases: Analgesic &
orthopaedic belt
Severe cases: Zimmer frame and
bed rest O Warda 34

35. Normal non-pregnant pelvis
Total gap width of up to 9mm is normal
during pregnancy
Abnormal gap is considered to be ≥ 10mm
(note misalignment)
O Warda 35

36. 36
Orthopedic belt
Zimmer frame
O Warda

37. Thank You
O Warda 37