PUERPERIUM & PUERPERIUM & PUERPERAL SEPSISPUERPERAL SEPSIS

DR. IQBAL TURKISTANIDR. IQBAL TURKISTANI

Asst. Prof. & ConsultantAsst. Prof. & Consultant

Ob/Gyn Dept.Ob/Gyn Dept.

PUERPERIUMPUERPERIUM

=The time during which:=The time during which: - all the physiological changes of pregnancy is reversed - all the physiological changes of pregnancy is reversed

- and the pelvic organs return to their previous state - and the pelvic organs return to their previous state

- and endocrine influence of the placenta is removed- and endocrine influence of the placenta is removed

~6 wks(~6 wks(++ 40 days) … 1 40 days) … 1stst two weeks, the changes are rapid two weeks, the changes are rapid & become slower thereafter.& become slower thereafter.

Lactation is establishedLactation is established

It is a time of physiological and mental adjustment to the It is a time of physiological and mental adjustment to the new environment with the arrival of a new babynew environment with the arrival of a new baby

OBJECTIVES OF MEDICAL & OBJECTIVES OF MEDICAL & NURSING CARE DURING THE NURSING CARE DURING THE PUERPERIUMPUERPERIUM

1.1. Monitor physiological changes of Monitor physiological changes of puerperiumpuerperium

2.2. To diagnose and treats any To diagnose and treats any postnatal complicationspostnatal complications

3.3. To establish infant feedingTo establish infant feeding

4.4. To give the mother emotional supportTo give the mother emotional support

5.5. To advise about contraceptionTo advise about contraception

II THE PELVIC ORGANS:THE PELVIC ORGANS:

1. Uterine involution1. Uterine involution

after delivery: uterine fundus after delivery: uterine fundus palpable at level of umbilicuspalpable at level of umbilicus

10-14 days later, 10-14 days later, disappears disappears behind the behind the symphysis pubis.symphysis pubis.

This process is aided by This process is aided by oxytocinoxytocin during breast during breast feeding feeding

Delay in involution = Delay in involution = infection infection or retained or retained products of products of placentaplacenta

2.2. THE CERVIXTHE CERVIX

After delivery: flacid and After delivery: flacid and curtain like curtain like

Few days Few days original form & original form & consistencyconsistency

External os dilated (one External os dilated (one finger (weeks—months)finger (weeks—months)

Internal os is closed to lessInternal os is closed to less than one finger by the 2than one finger by the 2ndnd

week of the puerperium.week of the puerperium.

3.3. THE VAGINATHE VAGINA::

11stst few days of puerperium, few days of puerperium, vaginal wall is smooth, soft vaginal wall is smooth, soft and oedmatousand oedmatous

Slight distention return to normal Slight distention return to normal capacity in few days capacity in few days

Episiotomy and tears of vagina Episiotomy and tears of vagina and perineum heal well.and perineum heal well.

Healing is impaired in presence of Healing is impaired in presence of haematoma or infection haematoma or infection

4.4. ENDOMETRIUM CAVITY:ENDOMETRIUM CAVITY:

Decidua is cast off as a result of Decidua is cast off as a result of ischemia ischemia lochial flowlochial flow

Lochia= blood, leucocytes, shreds Lochia= blood, leucocytes, shreds of decidua and organisms. of decidua and organisms.

Initially; dusky red, fades after Initially; dusky red, fades after one week, clears within 4 weeks one week, clears within 4 weeks of delivery.of delivery.

New endometrium grows from New endometrium grows from basal layer of decidua.basal layer of decidua.

OTHER SYSTEMS:OTHER SYSTEMS:

Bladder & UrethraBladder & Urethra- Within 2-3 weeks - Within 2-3 weeks hydroureter and calycial hydroureter and calycial

dilatation of pregnancy is much less evident.dilatation of pregnancy is much less evident.

- Complete return to normal - Complete return to normal 6-8 weeks 6-8 weeks

- Diuresis during first day- Diuresis during first day

BloodBlood

-- -- Plasma volume Plasma volume

- Blood clotting factors and platelet - Blood clotting factors and platelet count rise after deliverycount rise after delivery

- Fibrinolytic activity (which occurs - Fibrinolytic activity (which occurs during pregnancy) is reversed within 30 during pregnancy) is reversed within 30

min. of placental delivery.min. of placental delivery.

COMPLICATIONS OF THE PUERPERIUM COMPLICATIONS OF THE PUERPERIUM

SERIOUS AND SOMETIMES FATAL DISORDERSSERIOUS AND SOMETIMES FATAL DISORDERS MAY ARISE DURING THE PUERPERIUMMAY ARISE DURING THE PUERPERIUM

I.I. Thrombosis & Embolism :Thrombosis & Embolism := One of the main causes of = One of the main causes of maternal death.maternal death.

II.II. Puerperal Infection :Puerperal Infection : Puerperial Puerperial PyrexiaPyrexia

= A clinical sign that merits = A clinical sign that merits careful careful investigation. investigation.

= A temperature of 38 oC on any = A temperature of 38 oC on any occasion in the first 14 occasion in the first 14

days days delivery. delivery.

CAUSES:CAUSES:

1. Urinary tract infection1. Urinary tract infection

2. Genital tract infection2. Genital tract infection

3. Pelvic / intra-uterine 3. Pelvic / intra-uterine

infectioninfection

4.4. Breast infection Breast infection

5. Deep vein thrombosis (DVT)5. Deep vein thrombosis (DVT)

6. Respiratory infection6. Respiratory infection

7. Other non-obstetrics causes7. Other non-obstetrics causes

8. Surgical wounds e.g. C.S.8. Surgical wounds e.g. C.S.

DX / INVESTIGATIONDX / INVESTIGATION

• Full Clinical ExaminationFull Clinical Examination• MSUMSU• Cervical & HVSCervical & HVS• Sputum C/S (if possible)Sputum C/S (if possible)

&& Blood cultureBlood culture

MANAGEMENT:MANAGEMENT:After investigation is sent forAfter investigation is sent forStart antibiotics if situation Start antibiotics if situation

warrantswarrants

III. MASTITIS :III. MASTITIS :

i.i. Acute intramammary mastitisAcute intramammary mastitis= due to failure of milk withdawal = due to failure of milk withdawal

from from a lobulea lobuleRx Rx breast feeding, cold compress , breast feeding, cold compress ,

antibiotics if no improvement antibiotics if no improvement within 24 hrs. within 24 hrs.

ii.ii. Infective mastitisInfective mastitis : := May be due to staph. Aureus = May be due to staph. Aureus Rx. Antibiotics according to sensitivityRx. Antibiotics according to sensitivity

iii.iii. Breast abscess formation :Breast abscess formation := Rare but preventable= Rare but preventableRx.- Surgical drainage if established.Rx.- Surgical drainage if established. - antibiotics, only if early.- antibiotics, only if early.

IV. SECONDARY POSTPARTUM IV. SECONDARY POSTPARTUM HAEMORRHAGE:HAEMORRHAGE:

= Excessive blood loss from = Excessive blood loss from genital tract more than 24 hr genital tract more than 24 hr and within 6 weeks of and within 6 weeks of

deliverydelivery

CausesCauses

i. Retained placental fragments i. Retained placental fragments ii. Blood clotsii. Blood clots

~ Usually within a few days of ~ Usually within a few days of deliverydelivery(Commonest between 8-14 days)(Commonest between 8-14 days)

MANAGEMENT :MANAGEMENT :

Mild bleeding Mild bleeding observeobserve IV fluid /blood + oxytocic drugIV fluid /blood + oxytocic drug Evacuation of uterus under GA ifEvacuation of uterus under GA if - USS suggests presence of- USS suggests presence of

retained placental tissueretained placental tissue - Heavy bleeding persists- Heavy bleeding persists - & the uterus is larger than - & the uterus is larger than

expected and tender; the cervix is expected and tender; the cervix is open.open. - The infection is treated - The infection is treated appropriately.appropriately.

V. PUERPERIAL MENTAL DISORDERSV. PUERPERIAL MENTAL DISORDERS::

i.i. Fourth day bluesFourth day blues anxiety and depressionanxiety and depression

ii.ii. Puerperal psychosisPuerperal psychosis

Uncommon, however seriousUncommon, however serious ? Due to endocrine changes in puerperium, or are an ? Due to endocrine changes in puerperium, or are an

uncovering of an underlying psychotic tendency at a uncovering of an underlying psychotic tendency at a vulnerable stage.vulnerable stage.

Psychiatrist opinion is seeked hence risk of suicide and Psychiatrist opinion is seeked hence risk of suicide and safety of baby are paramount consideration.safety of baby are paramount consideration.

Warning signs : Confusion, restlessness, extreme Warning signs : Confusion, restlessness, extreme wakefulness, hallucination and deliriumwakefulness, hallucination and delirium

TREATMENTTREATMENT According to severityAccording to severity

Observe, discuss, mild sedativesObserve, discuss, mild sedatives If severeIf severe heavy sedation + transfer to heavy sedation + transfer to psychiatric wardpsychiatric ward