2. Definition of Normal Puerperium
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 .
3. Divided into
–First 24 hours
–Early- up to 7 days
–Remote- up to 6 weeks
4. Objectives
To monitor physiological changes of
puerperium
To diagnose and treats any postnatal
complications
To establish infant feeding
To advise about contraception
5. Physiological changes in Normal
Puerperium
Changes in Genital Tract
Changes in breast and Lactation
Changes in other systems
6. Changes in Genital Tract
Involution of the Uterus
Lochia
Involution of Other Pelvic Organs
Menstruation
7. Uterine involution
A. Immediately after delivery:
fundus palpable at
level of umbilicus
B. 10-14 days later,
At level of the
symphysis pubis.
C. 6 WKS post partun :
non pregnant size
8. Endometrium Cavity
Decidua is cast off as a result of ischemia
→ lochial flow
Lochia= blood, leucocytes, shreds of
decidua and organisms.
Initially; dusky red3-4 days(rubra), fades
after one-two week(serosa), clears within 4
weeks of delivery(alba).
New endometrium grows from basal
layer of decidua.
9. Cervix:
It has reformed within several hours of
delivery
it usually admits only one finger by 1
weeks
the external os is fish-mouth-shaped
it return to its normal state at 4 weeks
after birth
10. Ovarian function
Return of menstruation
* non-nursing mothers:
menstruation returns by 6 – 8 weeks.
* nursing mothers:
may develop lactating amenorrhea.
time of ovulation is 3 months in non-
breast -feeding women
11. Changes in Breast and Lactation
Mamogenesis (Mammary duct-
gland growth & dev.)
Lactogenesis (Initiation Of
milk secretion in alveoli)
Galactopoiesis (Maintenance of
Lactation)
12. Changes in other systems
Pulse slow
Temp. subnormal
Shivering
Fever up to first 24 hours
Hb. Rises
TLC increases
Diuresis- 2nd to 5th day post delivery
13. OTHER SYSTEMS:
OTHER SYSTEMS:
Bladder & Urethra
- Within 2-3 weeks
Hydroureter and calycial dilatation of pregnancy is much less evident.
- Complete return to normal → 6-8 weeks
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.
15. Daily round by physical staff should
incluid:
Uterus: palpate uterine funds to evaluate
level and tone
Abdomen: examine for distension especially
postoperative
Lochia :for quantity ,and unusual odors
Perineum: inspected for hematoma
formation ,signs of infections, or wound
breakdown.
16. Bladder: function may be abnormal after
traumatic delivery or epidural anethesia.
(Catheter may be left in place for 24 hr if there
is marked periurtheral edema or repair).
Breasts :examined for engorgement or signs
of infection
Lungs :evaluated in all post CS patients.
Extremities :because post partum pt are at
increased risk of DVT especially post CS.
17. Post partum immunization
Adminster a booster dose in
Rubella non immune wommen or
MMR vacine.
Adminster 300 ug of RhoGAM
within first 72 hours after delivery
to RH –ve mothers .
18. Breast feeding should be Encouraged
Help in rapid uterine involution, decreased risk
of ovarian ,breast cancer,osteprosis.
Women shouldn't breastfed if:
Have infant with galactosemia
Are infected with HIV.
Have active untreated TB.
Are being treated for breast cancer.
19. Contraceptive advice
Breast feeding women shouldn’t relay on
lactation amenorrhea as a method of
contraception (98% protection in first 6
months provided that feeding every 4 hours
daily ,6 hours at nigth ,formula supply 10-
15%)
Use a barrier method or hormonal
contraception .POP 2-3 weeks postpartum
DMPA 6 weeks postpartum
20. Health& nutrition education
Health & nutrition education
Calorie need per day-2200+700 =2900
Care of MLE stitches if any
Care of nipples and areola
Sexual intercourse can be resumed after 6
weeks after delivery
Immunization of child
23. Benign single-day fevers following
vaginal delivery
Fever in the first 24 hours after
delivery often resolves spontaneously
and cannot be explained by an
identifiable infection.
24. Significance
Significance
Fever is not an automatic indicator of
puerperal infection.
A new mother may have a fever owing to prior
illness or an illness unconnected to childbirth.
However, any fever within 10 days postpartum
is aggressively investigated.
Physical symptoms such as pain, malaise, loss
of appetite, and others point to infection.
28. Treatment
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.
29. Endometritis
The most typical site of infection is the
genital tract.
Endometritis, which affects the uterus,
is the most prominent of these
infections.
Endometritis is much more common if
a small part of the placenta has been
retained in the uterus.
30. Atelectasis
Caused by hypoventilation and is
best prevented by coughing and deep
breathing on a fixed schedule
following surgery
31. Acute pyelonephritis Acute
Has a variable clinical picture, and
postpartum, the first sign of renal
infection may be fever, followed
later by costovertebral angle
tenderness, nausea, and vomiting.
32. Wound infections
Incisional abscesses that develop following
cesarean delivery usually cause persistent
fever beginning about the fourth day
Perinealinfection uncommon , caused by
bacterial contamination during delivery
Antimicrobials and surgical drainage, with
careful inspection to ensure that the fascia
is intact.
34. Septic Thrombophlebitis
A dignosis of exclusion .
Thrombous spread by lymphatic's to
the iliac vessels or directly via the
ovarian vessels.
Suspected by intermittent spiky fever
which fails to response to ordinary
antibiotics and improved with heparin
.
37. 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.
39. Clinical course & severity of theisinfection is
clinical course & severity of the infection determined by
determined by
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.
43. Puerperal infection following vaginal delivery
primarily involves the placental implantation site,
decidua and adjacent myometrium, or
cervicovaginal lacerations.
Uterine infection following cesarean delivery is that
of an infected surgical incision
Bacteria that colonize the cervix and vagina gain
access to amnionic fluid during labor, and
postpartum, they invade devitalized uterine tissue.
44. UTERINE INFECTIONS
Postpartum uterine infection has been called
variously endometritis, endomyometritis, and
endoparametritis.
Because infection involves not only the
decidua but also the myometrium and
parametrial tissues, the inclusive term metritis
with pelvic cellulitis.
45. Predisposing factor
The route of delivery is the single most
significant risk factor for the development
of uterine infection
1- to 6-% incidence of metritis after
vaginal delivery.
If there is intrapartum chorioamnionitis, the
risk of persistent uterine infection increases
to 13 %
46. CESAREAN DELIVERY
Single-dose perioperative antimicrobial
prophylaxis is given almost universally
at CS
10-50% incidence of metritis after CS
Women with CS after labor (risk factors
factors) who were not given perioperative
prophylaxis had a 90-percent serious
pelvic infection rate
49. Signs
Pyrexia and tachycardia
Uterus is large and tender
Parametrial tenderness (parametritis)or
fullness in pelvis due to abscess is
elicited on abdominal and bimanual
examination
peritoneum and paralytic ileus (severe
cases).
50. Investigations
1. CBC anaemia, Leukocytosis
may range from 15,000 to 30,000 cells/L,
but recall that cesarean delivery itself
increases the leukocyte count
2. Coagulation Profile DIC.
3 Arterial blood gas acidosis &
hypoxia. ( septiceamic shock)
51. Bacterial cultures
4-Routine pretreatment genital tract
cultures are of little clinical use and
add significant costs
5-Similarly, routine blood cultures
seldom modify care(25% +ve in septic
Pelvic thrombo phelbities.
52. Investigations
6.Urine analysis: white blood cell
casts is diagnostic of pyelonephrities.
7-Pelvic US :
Retained products
Adnexal mass in pelvic abscess.
CT: Occult abscess or thrombous in
tthrombophelbities.
54. Prevention
Awareness of general hygiene
principles
Good surgical technique with proper
hemostasis.
Prophylactic antibiotics especially in
emergency CS.a single intra operative
dose of cphalosporin+ metronidazole.
55. Treatment
Begins with I.V. infusion of broad
spectrum antibiotics and is continued
for 48 hours after fever is resolved.
Surgery may be necessary to remove
any remaining products of conception
or to drain local lesions, such as an
infected episiotomy .
57. CLINDAMYCIN-GENTAMICIN
REGIMEN
had a 95-percent response rate still considered by
most to be the standard by which others are
measured
Because enterococcal infections may persist despite
this standard therapy, many add ampicillin to the
clindamycin-gentamicin regimen, either initially or
if there is no response by 48 to 72 hours.
58. Patients with persistant fever despite
antibiotics TTT are assessed for
Ratained product of conception
Wound infection
Pelvic abcess
Ovarian vein thrombosis
Septic pelvic thrombophelbities.
61. * 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.
*
62. Necrotizing fasciitis of the episiotomy site
may involve any of the several superficial or
deep perineal fascial layers, and thus may
extend to the thighs, buttocks, and abdominal
wall
63. in addition to signs of infection ,there
is extensive necrosis
managed by surgical removal of the
necrotic tissue under general
anesthesia and split-thickness skin
grafts
65. A 28-year-old primigravid underwent a
cesarean section secondary to having a
breech presentation and rupture of
membranes at 36 weeks gestation.
The cesarean section was
uncomplicated, but on postpartum day
two the patient was having fever
(38.5C) and uterine tenderness.
66. A diagnosis of postpartum
endometritis was made and the
infection was treated with Mefoxine
1 g IV Q8H.
67. After 24 hours of antibiotics, the patient
presented pain in the right lower abdomen
and loin, and her WBC count was
12000/mm3. She continued to spike fevers .
On Abdominal exam :
Soft, flat abdomen
Tenderness on the right iliac fossa
No rebound-tenderness,
Mcburney’s point (+/-),Murphy’s sign(-),
Kindey region percussion (-).
69. On postpartum day four
The patient’s condition showed no
improvement after antibiotic treatment,
An abdominal CT scan was obtained.
A right ovarian vein thrombosis was noted
on the imaging.
Diagnosis : ovarian vein thrombophlebitis
70. The patient started therapeutic
enoxaparin(clexane).
After 48 hours of anticoagulation, the patient
was afebrile and asymptomatic.
The patient was discharged home after being
anticoagulated with warfarin
After 6 weeks a CT scan was repeated. The
right ovarian thrombosis was not present in
the images and warfarin was discontinued
71. How to prevent ?
Avoid the risk factors
Keep the episiotomy site clean
Careful attention to antiseptic procedures
during childbirth is the basic key of
preventing infection.
Administer prophylactic antibiotics with
Cesarean section, PROM, cardiac
,diabetic patients and with any uterine
manipulation.
73. Which change can be seen in puerperium?
A-maternal heart beat is increased 2 days after
delivery
B- endometrium repair is resumed three
weeks after delivery
C- Ureters will return to non pregnant state
after 8 weeks
D- Vaginal rugae appear after 3 months from
delivery
Ans:C
74. Which is true about puerpural changes?
A- total number of uterine muscular cells is
not reduced
B-vaginal rugae occur in the third month from
delivery
C-uterine connective tissue won’t change
D-uterine is re-epithelialized totally in the
first week of pregnancy
Ans:A
med-ed-online
75. Which organism is the least responsible in
puerpural infection?
A- peptostreptococcus
B-enterococcus
C- chlamydia trachomatis
D-mycoplasma
Ans:D
76. A patient comes to the clinic because of fever 4
days after C/S which persists 72 hours from
antibiotic administration. What is the most likely
reason of antibiotic failure?
A- wound infection
B- pelvic thrombophlebitis
C- pyelonephritis
D- adenexal infection
Ans:A
med-ed-online
77. What is wrong about puerpural immunization?
A- tetanus and diphtheria vaccine before
discharge from hospital is advocated
B-a woman already injected measles vaccine
does not need a booster dose
C- Rh negative women with an Rh positive
newborn should take RhoGam
D- women who have never taken rubella
vaccine should be vaccinated
Ans:B
78. Which is wrong about fever after
delivery?
A-fever more than 39 c in the first 24 hours after
delivery is a sign of severe infection
B-fever in bacterial mastitis usually is late and
persistent
C-pulmonary infection usually occurs in the first
24 hours mostly after C/S
D-pyelonephritis is one of the most common
reason of infection and is most often mistaken
for pelvic infection
Ans: D
79. A woman has gone through C/S 7 days ago .
Three days after the operation chills and fever
(enigmatic fever) occured. She is given
antibiotic with no improvement in her condition.
She doesn’t look ill. What is your diagnosis?
A-pelvic abscess
B-parametrial phlegmon
C-pelvic septic thrombophlebitis
D-adenexal infection
Ans:C
80. Who can lactate?
A- mother of a galactosemic newborn
B- mother with HBV
C- mother with active untreated TB
D-mother with breast herpetic lesions
Ans:B
81. An infection after C/S which is not
responsive to clinda+genta is because of:
A-clostridium
B-enterococcus
C-bacteroid fargilis
D-chlamydia trachomatis
Ans:B
82. What is true about lactation period
mastitis?
A-It occurs in the last days of the first week
B- Most of the time it is bilateral
C-nose and throat of the newborn is the
source of infection
D-it is mostly a result of coagulase-negative
staph
Ans:C