dr a.o. ogunlaja senior lecturer/consultant …
TRANSCRIPT
DR A.O. OGUNLAJA
SENIOR LECTURER/CONSULTANT OBSTETRICIAN GYNAECOLOGIST
OUTLINE Introduction
Physiological Changes
Uterine involution
Lochia
Genital tract changes
The breast and lactation
Other systems
• Puerperal disorders
INTRODUCTION Puerperium is a six week period following
completion of third stage of labour, when
considerable adjustments occur before return to
the pre-pregnant state.
It is a period of considerable psychological
vulnerability.
PHYSIOLOGICAL CHANGES
The physiological changes includes;
1. Uterine involution
2. Lochia
3. Genital tract changes
4. The breast and lactation
5. Resumption of menses
6. Other systems
Uterine Involution This is the process by which the postpartum
uterus, weighing about 1000grams(1kg) returns
to its pre-pregnancy state of less than 100grams.
Immediately after delivery, the uterine fundus lies
at about the umbilicus, in some cases it may be
about four(4)cm below the umbilicus or even
12cm above the symphysis pubis.
When there is coexisting fibroid the uterine
fundus may lie above the umbilicus.
Uterine Involution
Uterine involution is achieved by a process of
autolysis.
Autolysis is the enzymatic digestion of cytoplasm
of muscle cells including digestion of blood clots,
some blood vessels and other fibroelastic tissues.
This virtually has no effect on the number of
muscle cells, and the excess protein produced
from autolysis is absorbed into the bloodstream
and excreted in the urine.
Causes Of Delayed Involution
Uterine infection
Retained products of conception like placenta tissue, fetal membrane and occasionally blood clots
Uterine Fibroids
NOTE:
A delay in involution in the absence of any other signs or symptoms e.g. bleeding or delay in lochia resolution is of no clinical significance.
LOCHIA Lochia is a blood-stained uterine discharge that
is comprised of blood and necrotic decidua. Only
the superficial layer of decidua becomes necrotic
and is sloughed off.
The lochia consists of erythrocytes, shreds of
decidua, epithelial cells, leucocytes and bacteria
which invade the uterine cavity from the vaginal
commensals.
Types Of Lochia
1. Lochia Rubra
2. Lochia Serosa
3. Lochia Alba
1.Lochia rubra; is seen for the first 3-4 days after
delivery. it is red in colour. Persistent rubra
suggests delay in involution.
2.Lochia serosa; is seen for about 5-9 days after
delivery. It is pale in colour compared to rubra
3.Lochia alba; is seen about the 10th day after
delivery. It is yellowish white in colour.
GENITAL TRACT CHANGES Cervix;
the cervix is flaccid and hypertrophied after delivery with the internal and external os open. With these changes, the cervix shrinks down rapidly and the internal os and external os gradually reduce in size; the internal os becomes closed on finger examination towards the second week of the puerperium although the external os may remain open for quite a variable period beyond the end of puerperium.
GENITAL TRACT CHANGES Vagina;
The vagina is usually dilated and stretched out
with flattening and smoothening of the vaginal
wall. Within a few days after delivery, it shrinks
down to its normal capacity with return of some
of the rugae.
The fourchette and introitus return to their pre-
pregnancy state gradually.
The Breast And Lactation
Recall anatomic & physiologic changes of breast in pregnancy
Proliferation of ducts & alveoli. Increased lobules by hyperplasia & later hypertrophy.
After delivery, marked increased size of alveolar cells & secretory organelles, ultimately distension of the alveoli by milk
Colostrum is secreted (higher Immunoglobulin & White Blood Cells, lower fat & lactose)
Concentration of fat & lactose increase rapidly first two weeks Postpartum.
RESUMPTION OF MENSES
Amenorrhea
Duration & frequency of breast feeding important factors
In non-breast feeding mothers, 1st postpartum menses
occurs approx 55 – 60days (range 20 – 120days).
Frequency of ovulation increases the farther from delivery
1st menses occurs
(84% of cycles ovulatory after 60 DPP versus 52% when
less than 60days)
Wider variation in return of menses in breast feeding women
NB – Elevated prolactin inhibits ovarian response to FSH
Suckling increases normal pulsatile release of FSH & LH, by
interfering with hypothalamic GnRH.
MANAGEMENT OF NORMAL PUERPERIUM Early discharge
Perineal Care( sitz bath, perineal hygiene, Analgesics)
Breast Care
Good nutrition
Health Education
Immunization
Resumption of coitus
Social support
Contraception and family planning Counselling
Follow-up Visit
PUERPERAL DISORDERS Perineal complications
Bladder dysfunction
Bowel dysfunction
Secondary postpartum haemorrhage
Obstetric palsy( foot drop)
Symphysis pubis diastesis
Puerperal pyrexia
Sheehan’s syndrome
Psychiatric disorders
Perineal complications Perineal discomfort is the single major problem for
mothers, and about 80% complain of pain in the first 3 days after delivery, with a quarter continuing to suffer discomfort at day 10.
Discomfort is greatest in women who sustain spontaneous tears or have an episiotomy, but especially following instrumental delivery.
Infections of the perineum are generally uncommon considering the risk of bacterial contamination during delivery.
This complaint alongside with the discharge of lochia can affect resumption of coitus
Bladder function Voiding difficulty and over-distension of the bladder
are common after childbirth, especially if regional
anaesthesia ( epidural/spinal) has been used.
Over-stretching of the detrussor muscle can dampen
bladder sensation and make the bladder
hypocontractile, particularly with fibrous replacement
of the smooth muscle.
Bowel function Constipation is a common problem in the
puerperium. This may be due to an interruption in
the normal diet and possible dehydration during
labour.
Advice on adequate fluid intake and increase in fibre
intake may be all that is necessary.
Secondary postpartum hemorrhage Secondary postpartum hemorrhage(PPH) is defined
as fresh bleeding from the genital tract between 24 hours and 6 weeks after delivery.
The most common time for secondary PPH is between days 7 and 14, and the cause is most commonly attributed to retained placental tissue.
The management of heavy bleeding includes an intravenous infusion and antibiotics in cases of infection, cross-match of blood, syntocinon, an examination under anaesthesia and evacuation of the uterus.
Obstetric palsy Obstetric palsy or traumatic neuritis, is a condition in
which one or both lower limbs may develop signs of
a motor and/or sensory neuropathy following
delivery.
Presenting features include sciatic pain, foot-drop,
parasthesia, hypoaesthesia and muscle wasting.
The mechanism of injury is unknown and it was
previously attributed to compression or stretching of
lumbrosacral trunk as it crosses the sacroiliac joint
during the descent of the fetal head.
Obstetric palsy It is now believed that herniation of the lumbrosacral
discs ( L4 or L5) can occur, particularly in the
exaggerated lithotomy position and during
instrumental delivery.
An orthopeadic surgeon and physiotherapist opinion
should be sought and management includes bed
rest with a firm broad beneath the matress,
analgesia and physiotherapy.
Symphysis pubis diasthesis Separation of the symphysis pubis can occur
spontaneously in least 1 in 800 vaginal deliveries.
Deliberate surgical separation of the pubis in labour (symphysiotomy) is rarely in extreme cases of shoulder dystocia.
It is important to note that this seperation may occur spontaneously in some cases of difficult vaginal deliveries.
Treatment includes bed rest, anti-inflammatory agents, physiotherapy and pelvic corset to provide support and stability.
Thromboembolism The majority of death in puerperium and are more
common after caesarean section.
It is worthy to note that there is a hypercoagulable
state in pregnancy and peurperium.
If deep vein thrombosis or pulmonary embolism is
suspected, full anticoagulant therapy should be
commenced, and a lower limb compression
ultrasound and/or lung scan should be carried out
within 24-48 hours.
Puerperal pyrexia Significant puerperal pyrexia is defined as a
temperature of 38 centigrade or higher on any two
of the first 10 days postpartum, exclusive of the first
24 hours (measured orally by a standard technique)
A mildly elevated temperature is not uncommon in
the first 24 hours, but any pyrexia associated with
tachycardia merits investigation.
In about 80% of women who develop a temperature
in the first 24 hours following vaginal delivery, no
obvious evidence of infection can be identified.
Puerperal pyrexia Common sites associated with puerperal pyrexia
include chest, throat, breasts, urinary tracts, pelvic
organs, ceasarean section or perineal wounds.
Causes; Malaria, puerperal sepsis, mastitis, Urinary
Tract Infection, chest infection, wound infection.
Puerperal sepsis Puerperal sepsis is infection of the genital tract.
It is usually due to poly microbial organism. It
involves contaminants from the bowel that colonize
the perineum and genital tract.
The frequently identified is group B streptococcus
The risk factors include; chorioamnionitis, prolonged
rupture of membrane, instrumental delivery.
Organisms commonly associated with pueperal sepsis Aerobes Anaerobes
Gram positive
1. Beta-hemolytic
streptococcus
2. Staphylococcus
epidermidis
Gram negative
1.Escherichia coli
2.Heamophilus influenza
3.Klebsiella pneumonia
4.Pseudomonas aeruginosa
1.Peptococcus sp
2. Peptostreptococcus sp
3.Bacteroides species- B
fragilis, B. bivius, B. disiens
Miscellaneous
1. Mycoplasma hominis
2. Chylamdia trachomatis
Mastitis Inflammation of the mammary gland
Milk stasis & cracked nipples contribute to the influx of skin flora
• Clinical Presentation; • Fever, chills, myalgias, warmth, swelling and breast
tenderness • Exam Findings; • Area of the breast that is warm, red, and tender • Treatment; • moist heat,massage,fluids,rest,Proper positioning of
the infant during nursing,Nursing or manual expression of milk,analgesics,antibiotics
Sheehan’s syndrome COMPONENTS OF SHEEHAN’S SYNDROME
Absence of lactation
amenorrhea
Loss of axillary & pubic hair
Genital & breasts atrophy
Super-involution of the uterus
Infertility
Hypothyroidism
Adreno-cortical insufficiency
Psychological Disorders in Puerperium
Puerperium Blues Transient disorder
Lasts hours to weeks Bouts of crying and sadness
Puerperium Depression More prolonged affective disorder
Weeks to months Symptoms and signs of depression
Puerperium Psychosis First postpartum year Group of severe and varied disorders (psychotic symptoms)
Thank You For Listening