DR FOUZIAGUL

IT IS A PERIOD OF 6 WEEKS (42

DAYS) FOLLOWING THE BIRTH
OF A CHILD DURING WHICH ALL
THE
PHYSIOLOGICAL
AND
ANATOMICAL CHANGES, WHICH
HAVE
OCCURRED
DURING
PREGNANCY RETURN BACK TO
THEIR NORMAL LEVEL

To monitor the physiological changes of

puerperium i.e.
To diagnose and treat any post natal
complication
To establish infant feeding
To give the mother the emotional support
To advise about contraception

Placenta-the main hormonal supply,

responsible for all pregnancy changes
PELVIC ORGAN CHANGES
WEIGHT
BLOOD
OTHER SYSTEMS
OTHER CHANGES

UTREUS:
Immediately after delivery
About 18 cm long ,palpable at level of
umbilicus and weighs 1000 gm
At the end of first week, it is 12 cm &500
gms
At the end of second week it disappears in
pelvis & weighs about 300 gms
The rate of involution is relatively slow after
C/section than after normal delivery

The decidua is shed and zona basalis remains

intact ,from which new endometrium
regrows
Maximum involution is achieved at around 6
weeks but never regains its nulliparous size
being 20 % larger than before pregnancy
The speed of involution is unaffected by
breast feeding
The reduction in size is due to contraction
of myometrial fibers not b/c of autolysis

CERVIX
Receives some kind of permanent damage
but regains its shape and consistency rapidly
At end of second week, the internal os hardly
admits one finger & is closed at 6 weeks, the
external os is not unusual to stay open
permanentaly

VAGINA AND SUPPORTING STRUCTURES

Soon after delivery, vagina is capacious and
smooth walled passage. It regains its size
with rugae appearance in 3-4 weeks
Return of supporting structures of uterus and
pelvic joints may take 6 weeks and is often
incomplete

Normal perpeural vaginal discharge

Shreds of decidua , remains of trophoblastic
tissues, blood , leucocytes and organisms
It begins as frank blood , then lochia Rubra
b/c of cotribution from clotts, lochia serosa
when it is brownish pink and eventually
yellow white lochia alba which appears on
10th postnatal day

Pica disappear abruptly after delivery

The esophageal reflux is corrected in 24 hrs
& reduction of bowel motility is corrected in
3-4 days
With the initial rise in weight of 450 grams in
multi parous women only, the weight
continues to fall till 10 weeks after delivery

The hyperinsulinemia of pregnancy is

corrected in 2-3 days
The plasma glucose level falls below the late
pregnancy level during the first five
postpartum days, so glucose and insulin levls
are low in immediate post partum period
GTT

The plasma volume reduces by 20% & red cell

mass returns to prepregnancy level with in
first 24 hours
The Hb levels falls immediately due to blood
loss at delivery & is lowest on 4th postnatal
day
The diuresis begins at 2-4 days &continues
for 3-4 days and Hb raises to pre-parturition
level at the end of first week.
ESR rises in the first week & falls back to
prepregnancy level in the 4th week

There is transient fall in the coagulation

factors (fibrinogen,platelets)in the blood at
the time of placental separation b/c of their
consumption at placental site.
These factors recovers to high pre-delivery
levels with in 24 hours & remains high up to
two weeks postpartum.fibrinolytic activity
returns to normal within few hours of
parturition leading to rise in FDP
Plasminogen remains at pre-delivery level for
2-3 weeks

The HR & Heart sounds returns to normal

The cardiac output returns to normal in 2
weeks
Both systolic and diastolic BP returns to
normal at the end of first week
The lung volumes & capacity reverts to
normal at 2 weeks and tidal volume takes 6
weeks
The respiratory rate increases by 1/minute
during puerperiumi.e and returns to normal
in several weeks

The size of the kidneys begins to reverse

within 48 hrs and is completed with in 6
weeks
The dilatation of the upper urinary tract
reverts in 2 weeks
The bladder hypotonia is maintained in the
first postpartum week & returns to normal in
subsequent few weeks
Glycosuria of pregnancy is corrected in few
days
TSH returns in first week while thyroid
binding globulin cortisol may take 2-4 weeks

The divarication of recti and striae

gravidarum are permanent, though the
colour of later may fade.
Chloasma gravidarum and varicose veins
recover slowly
The backache improves with improvement in
posture

DR FOUZIA GUL

PUERPERAL PYREXIA
SECONDARY PPH
THROMBOEMBOLISM
URINARY PROBLEMS
THE PUERPERAL MENTAL DISORDERS

DEFINITION:
It is defined as temprature of 38 c or higher
On any two consecutive days within first 10
days postpartum but after first 24 hours
In first 24 hours, the rise in temprature is
reflection of tissue response to trauma
Subsequent inter current small rises in the
temprature are related to physiological
changes occurring in the uterus and are not
necessarily related to uterus

This definition applies to booked hospital

patients
In manipulated patients ,the infective
organisms have already been introduced and
the patient may have pyrexia due to
infection within first 24 hours

Endometritis
UTI
RTI
Wound infection
DVT
MASTITIS

PREDISPOSING FACTORS
C/Section
Prolonged rupture of membranes
Prolonged labor with multiple vaginal
examinations
RPOCS
Instrumental delivery
Mannual placental removal
Management of labour outside the hospital
Causative organasims:beta
hemolytic
organasims
streptococci(GP A & B),E coli,bacteroides
flagalis,clostridia,chlamydia

The protective barrier in the lower genital

tract are temporarily broken down
The placental site is raw area containing
NECROTIC TISSUE AND BLOOD CLOTTS which
is growth media for various organism
RPOCs, blood clotts ,ORGANISMS MULTIPLY
and penetrate from endometrium into the
myometrium, parametrium ,fallopian tubes
further into peritonium and even peripheral
circulation causing septicemia and
ENDOTOXIC SHOCK AND ABSCESS
FORMATION

CLINICAL FEATURES:
A LOCALIZED INFECTION:
INFECTION fever,feeling of
being unwell,foul smellind vaginal
discharge,secondary PPH
O/E: soft tender uterus with large size on
abdominal examination & pussy,profuse
pelvic discharge with open cervix
B ADENEXAL MASS:
MASS csytic swelling lateral to
uterus/abcesss in POD will be felt projecting
into post fornix
C SYSTEMIC INVOVEMENT:septicemia
INVOVEMENT
,endotoxic shock

PRE-DISPOSING FACTORS:
Short urethera with close approximation to
vagina
Asymptomatic bacteriuria
Catheterization
Previous history of UTI
CYSTITIS: urgency, frequency, dysuria
PYELONEPHRITIS:
PYELONEPHRITIS Pyrexia,s shivering ,loin
pain & tenderness at costovertebral area

More commonly seen in patients after GA for

C/section
Most common in patients who are smokers,
obese and suffer from chronic bronchitis
The clinical features includes productive
cough with ronchi, fever and poor inspiratiry
efforts

It includes episiotomy, perineal tears and csection scar

THE RISK FACTORS FOR WOUND INFECTIONS
c/section fop prolonged labour
Wound hematoma
placement of open drains
Obesity
Diabetes
Delayed and poor suturing technique

It ususally presents as fever and red swollen

tender breast in 3rd or 4th week
Cracked nipple is the predisposing factor
PELVIC TLROMBOSIS :most common after
C/Section than NVD
It often present as tender pelvic mass with
spiking fever
It is difficult to differentiate from pelvic
infection
Rapid response to heparin therapy is
diagnostic

THE HALLMARK OF MANAGEMENT

OF PUERPERAL PYREXIA

IS TO LOCATE
SITE

INFECTION

HISTORY: Antenatal record, labour detail ,

delivery notes, placental removal
History of urinary, respiratory and genital
tract infection
History of risk factors /predisposing factors
EXAMINATION:
GPE: temprature, pulse , BP,R/R, pallor,
jaundice, lymphadenopathy, dehydration
level
Throat examination,
Neck stiffness in case of epidural and spinal
anesthesia

BREASTEXAMINATION:
Engorgement,Inflammation,abscess
formation
Heart and Lung auscultation
DVT and Thrombophlebitis in lower limbs

VISCEROMEGALY: Liver and spleen

UTERINE SIZE: size, consistency, tenderness ,
mobility
RENAL ANGLE TENDERNESS:
BOWEL SOUNDS
WOUND EXAMINATION:
PELVIC EXAMINATION:
EXAMINATION
Inspection of external genitalia
Colour, amount ,odour of lochia
Speculum/digital pelvic examination

BLOOD COMPLETE: Hb,TLC/DLC,Platelet

count
PELVIC SCAN:
COLOUR FLOW DOPPLER for DVT
CULTURES: urine R/E and C/S
HVS, Wound swab, sputum for culture, blood
culture
X-RAY CHEST
BLOOD UREA AND ELECTROLYTES

RPOCS, Tubo-ovarian mass, pelvic abscess

Colour flow Doppler in DVT
X-Ray chest: lung infection, lung collapse
Blood urea and electrolytes: dehydrated
patients and those with renal failure

GENERAL MEASURES:
Hydration:
Anemia:
Analgesia:
Bladder/bowel care:
Urinary retention----- indwelling catheter
Distended bowel------- improves with the
correction of fluid and electrolyte balance

SPECIFIC TREATMENT
ANTIBIOTICS: commenced soon after taking
the specimen for C/S
SURGICAL TREATMENT:
RPOCS----- Evacuation and curetage after 1224 hours of commencement of antibiotics to
achieve adequate blood levels to deal with
organism which may get access to general
circulation leading to septicemia and septic
shock

TUBOOVARIAN ABSCESS:
It needs drainage if no response to
antibiotics in 48 hours
INFECTED WOUND: drainage and daily
dressing and debridement
BREAST ABSCESS: antibiotics, pain relief,
incision drainage
PHYSIOTHERAPY: especially in chest
infection
THROMBOPHLEBITIS: Heparin and
antibiotics

PUERPERAL INFECTION CAN BE PREVENTED

BY
Asepsis:
Identification of risk factors
Prophylactic antibiotics
Surgical technique: avoid manual removal of
retained placenta at c/section, peritoneal
lavage in high risk cases, proper hemostasis
and dead space occlusion, proper suturing
technique with appropriate suture material
PERSONAL HYGIENE:

URINARY RETENTION:
PAINFUL PERINEAL WOUND, CONTINUED
BLADDER HYPOTONIA
Failure to pass urine 6 hours after delivery
warrants abd exam to palpate bladder
TREATMENT:
INDWELLING CATHETER FOR 48 HOURS
May resolve spontaneously

URINARY INCONTINENCE:
Stress incontinence: seen in 10-25 % of
patients and is physiological in most cases
Reassurance and pelvic floor exercise is
treatment of choice
Fistula formation: which requires specialist
treatment

They are divided into three groups

POSTPARTUM BLUES
POSTPARTUM DEPRESSION
POSTPARTUM PSYCHOSIS

POSTPARTUM BLUES:
Experienced by 50-70% of the women world
wide
Insomnia, weepiness, depression, anxiety,
Headache, poor concentration , fatigue
Etiology : withdrawl of pregnancy
hormones
The symptoms reach peak by day 5
postpartum to recover quickly thereafter
TREATMENT: self limiting , no medication
needed, needs only reassurance , education,
emotional support

POSTPARUM DEPRESSION: is defined as the

occurrence of at least five of the following
symptoms
Depressed mood, insomnia or hyper-somnia
Significant changes in weight or appetite
Psychomotor agitation or retardation
Fatigue
Guilt
Feeling of worthlessness
Poor concentration
Indecisiveness
Recurrent suicidal thoughts

HOSPITALISATION:
DRUG THERAPY: SSRI,TRICYCLIC
ANTIDEPRESSANT,LITHIUM
Breast feeding may be continued with
tricyclic and SSRI
Breast feeding is contraindicated with
lithium, doxepin and flouxetin
The antidepressant should be continued for
at least 6 months

Psychotherapy:
ECT: required in some cases
Thyroid dysfunction must be excluded in all
patients with postpartum depression

Occurs in 2/1000 deliveries

Insomnia, weepiness, depresion, anxiety,
Headache, poor concentration, fatigue which are
associated mania and less often depression
The typical symptoms are thought disorders such
as delusion and hallucinations, patient feels that
baby is defective or dead or have desire to kill
the baby
D/D
sepsis, metabolic disturbances,
Intoxication , electrolyte imbalance must be
ruled out

Hospital admission
Baby isolation
Neuroleptic drugs:
chlopromazine,haloperidol
Antidepressant, lithium and bezodaizipne
may also be used
It takes 2-3 months to be improved
20-50 % risk of recurrence

2% of the women may have ovulation by 28th

day postpartum and may have an unplanned
pregnancy if contraception is not discussed
before going home
NONLACTATING MOTHERS:
IUCD may be inserted
OCP may be commenced at any day after 21
days
LACTATING MOTERS:
OCP is not used -----milk suppression

POP can be prescribed with high failure rates

but fertility is also reduced
Barrier methods can also be practised by
both parteners
Sterilization (BTL,Vasectomy) can be carried
out when family is complete, but it is done
few weeks after puerperium to enhance its
success rate