ABNORMALITIES

OF THE
PUERPERIUM
 DEFINITION

A rise of temperature reaching 1000F (380 C)

or more (measured orally) on 2 separate occasions
at 24 hrs apart (excluding first 24 hours) within first
10 days following delivery is called Puerperal
pyrexia.
 CAUSES…
PUERPERAL SEPSIS

URINARY TRACT INFECTION

MASTITIS
INFECTION OF CAESAREAN SECTION
WOUND

PULMONARY INFECTION

A RECRUDESCENCE OF MALARIA /
PULMONARY TUBERCULOSIS
PUERPERAL
SEPSIS
 DEFINITION

An infection of the genital tract which occurs

as a complication of delivery is termed
puerperal sepsis
 INCIDENCE

 Marked decline in cases:

 Improved obstetric care
 Availability of wider range of antibiotics
 Endometritis
Endomyometritis
Endoparametritis
• Doderlein bacillus (60-70%)
• Yeast like fungus –candida albicans
(25%)
• Staphylococcus albus or aureus
• Streptococcus –anerobic common
• E.coli
• Clostridium welchii
 PATHOGENIC FACTOR
FOR VAGINAL FLORA

The cervicovaginal mucous membrane is damaged even in

normal delivery and the uterine surface too, specially at the
placental site

is converted into open wound by the seperation of the placenta

which takes place during third stage of labor

the blood clots present at the placental site are excellent media
for the growth of the bacteria.
• Malnutrition and anemia
• Preterm labor
• Premature rupture of
membrane
• Chronic debilitating
illness (HIV)
• Prolonged rupture of
membrane >18hrs
• Diabetes
• Repeated vaginal examination
• Traumatic operative delivery
• Retained bits of placental tissue or membrane.
• Prolonged labour
• Hemorrhage
• Caesarean delivery
Puerperal infection is an wound infection. The
primary sites of the infection are:-
 Perineum
 Vagina
 Cervix
 Uterus
 PERINEUM

Laceration of the perineum are likely to be

infected.

The wound edges become red and swollen.

There may be collection of purulent discharge

resulting in complete disruption of the wound.
 VAGINA

Vaginal laceration are infected directly or by

extension from the perineal infection.

The mucosa is swollen and hyperaemic,

resulting in necrosis and sloughing
 Cervix:-
The cervical laceration becomes the site of infection

Uterus :-
The uterus is most common site of infection
Decidua (placental site) is common site and infected
first
The infection usually manifests between 3 rd and 6th
day of delivery
Pelvic cellulitis:- (lymphatics
/blood route)
• Causes exudation n formation
of indurated mass confined to
one side of the uterus
Salpingitis:- (lymphatic spread)
 infection of the fallopian tube
and ovaries with the formation of
tubo ovarian mass

Peritonitis :-
Localised pelvic abscess
 Thrombophelebitis :-
Ovarian vein of one side is usually involved
Uterine vein may also involved
Suppuration n embolism to other organs
Septicemia and pyemia:-
These may lead to endocarditis, pericarditis,
Renal abscess, lung abscess, meningitis or artheritis.

“These are rare these days with advent of potent

antibiotic”
Local infection-
Slight rise in temperature, generalised
malaise and headache.
Redness and the swelling of the local wound
Pus formation and disruption of wound
Uterine infection-
 Mild:
Pyrexia of variable degree and tachycardia.
Red, copius and offensive lochia.
Subinvoluted, tender and soft uterus.
 Sever infection-
Fever with chills and rigor
Rapid pulse
Scanty, odorless lochia
Subinvoluted uterus
Parametritis-
Sustained rise in temperature (7 th to 10th day)
Constant pelvic pain
Tenderness on either side of the hypogastrium
Unilateral, tender mass felt on vaginal examination
 Pelvic peritonitis:-
Pyrexia with increased pulse rate
Lower abdominal pain and
tenderness
Collection of the pus in pouch of
douglas
 Generalised peritonitis:-
High fever with rapid pulse
Vomiting
Abdominal pain
Tender and distended abdomen

Thrombophelebitis –
swinging fever with chills and rigor
Features of pyemia
 Septicemia-
High temperature with rigor
Rapid pulse
Headache, insomnia or mental confusion
Positive blood culture
Sign/symptoms of infection in the lungs,
meninges or joint
 Bacteriological study-
Smear
Culture and antibiotic sensitivity of
purulent material
High vaginal and cervial swabs
Peritoneal fluids
Blood culture
Urine :-

Routine and microscopic

examination
Culture if infection is suspected

Complete blood count-

Ultrasonography-
For diagnosis of pelvic masses
Pelvic abscess
Pelvic peritonitis
Retained bits of placenta and/ or membrane
Other specific investigation

X – ray
Blood for malaria parasite
SUBINVOLUTION
 DEFINITION

When the involution is impaired or retarded

it is called subinvolution.
 CAUSES:

 Grand multiparity,
 twins and hydramnios,
 Maternal ill health,
 Cesarean section,
 Prolapse of the uterus,
 Uterine fibroid.
 SYMPTOMS:

• The condition may be asymptomatic.

(1)Abnormal lochial discharge either excessive
or prolonged,
(2)Irregular or at times excessive uterine
bleeding,
(3) Irregular cramp like pain in cases of
retained products or rise of temperature in
sepsis
 SIGNS:

(1) The uterine height is greater than the normal for

the particular day of puerperium. It feels boggy and
softer.

(2) Presence of features responsible for subinvolution

may be evident.
 MANAGEMENT

Appropriate therapy is to be instituted only when

subinvolution is found to be a mere sign of some local
pathology:

(1) Antibiotics in endometritis,

(2) Exploration of the uterus in retained products,
(3) Pessary in prolapse or retroversion.
It is an infection of the urinary organs such as
kidney, ureter, urinary bladder and urethra.
• E. coli
• Klebsiella
• Proteus
• Staphylococcus aureus
 OTHER CAUSES ARE:-

 Recurrence of previous cystitis and pyelitis

 Infection contracted for the first time during
pregnancy is due to
Effect of frequent catheterization either during
labor or in early puerperium to relative retention
of urine.
Stasis of urine during early puerperium due to
lack of bladder tone and less desire to pass urine.
It is one of the common cause of
puerperal pyrexia, the incidence
being 1- 5 % of all deliveries.
 UTI is confirmed by examination of an
uncontaminated midstream clean catch sample for
urinalysis and culture and antibiotic sensitivity
test.
 High fluid intake

 Adequate drainage of urine

 Appropriate antimicrobial
therapy.
 BREAST
ENGORGEMENT
 CAUSES

Due to exaggerated normal

venous and lymphatic
engorgement.

Prevent the escape of milk from

lacteal system.
 INCIDENCE

In primiparous
 ONSET

Third and forth day

postpartum
 SYMPTOMS
Pain
Heaviness in both breast
Malaise
Rise of temperature
Painful breast feeding
 PREVENTION

Avoid prelacteal feeding

Initiate breast feeding early
and unrestricted
Exclusive breast feeding on
demand
Feeding in correct position
 TREATMENT

Breast supports
Manual expression of
remaining milk after each feed
In severe condition use breast
pump
CRACKED AND
RETRACTED
NIPPLES
IT OCCURS DUE TO LOSS
OF SURFACE EPITHELIUM
OR DUE TO A FISSURE
SITUATED AT THE TIP OR
BASE OF THE NIPPLE
 CAUSE

Crust formation over nipple due

to unhygiene
Retracted nipple
Trauma from baby's mouth
 SYMPTOMS

Asymptomatic condition
pain while feeding
 PROPHYLAXIS

Local cleanliness during pregnancy

and in puerperium before and after
each feeding
COMPLICATION

Mastitis
 TREATMENT
 Correct attachment will provide
immediate relief from healing and
pain
 Fresh human milk and saliva have
got an healing property
 breast pumps in severe cases