Puerperium

“Post Partum Complications”

Dr. Alaa M. Ismail, MD

JBOG, ArBOG
Puerperium
What is the Puerperium?

◼ The postnatal period includes 6 weeks after

delivery

◼ Changes that happened to the body in

pregnancy revert to its pre-pregnancy state
Normal Changes
◼ Cardiovascular system
▪ Initial sudden rise of afterload in the third stage and postpartum
▪ normalises by the second week

◼ Involution of uterus
▪ After delivery of placenta – 20 week size
▪ Reduces one finger breath per day
▪ Not palpable on 12th day
▪ At end of puerperium uterus only slightly larger than normal

◼ Lochia
▪ 3-4 days mainly blood and trophoblastic tissue
▪ 4-12 days yellow/brown in colour
▪ May persists up to 6 weeks
Common postpartum problems

◼ Perineal problems
◼ Urinary incontinence
◼ Bowel problems
▪ Constipation
▪ Haemorrhoids
◼ Mastitis
◼ Backache
◼ Psychological problems – ‘baby blues’
Common postpartum problems
◼ Perineum
▪ Pain, oedema and soreness
▪ Infection and dehiscence

◼ Stress urinary incontinence

▪ In about 50% of women - may persist
▪ Pelvic floor exercises

◼ Backache
▪ Affects 25% of women
▪ Might be considerable and persist several months
◼ Mastitis
▪ May be due to failure to express all milk
▪ Invest.: CBC, Breast US if abscess is suspected, Blood
culture if temp. more than 38
▪ Start with simple measures: worm compressors, pain
killer, continue feeding, express misl if baby is not
feeding
▪ If no improvement, occasionally Staph aureus infection
needs Flucloxacillin
▪ Breast abscesses are rarer and require I&D
Common postpartum problems
◼ Psychological problems
Risk factors: personal or family Hx. of psychiatric illness, traumatic
birth/preg. experience: IVD, CS, neonatal complications
1. Blues:
- baby blues on days 3-5 affect a large proportion of women and causes
sadness, emotional upset and resolves spontaneously
- mood swings, crying spells, anxiety and difficulty sleeping.

2. Depression:
◼ 10-15% of women develop postnatal depression at any time within the
first year after delivery
◼ Loss of appetite or eating much more than usual, insomnia, fatigue, loss
of energy, reduced interest, Intense irritability and anger, hopelessness,
Feelings guilty or inadequacy, restlessness
◼ Risk of recurrenc eis high next pregnancies
◼ Management: CBT, antidepressants SSRIs, admission if sever
Serious postnatal problems

◼ Postpartum haemorrhage

◼ Puerperial sepsis

◼ Venous thromboembolism

◼ Postnatal psychosis
Postpartum Haemorrhage

◼ Loss of more than 500mls of blood

▪ Primary postpartum haemorrhage

▪ < 24 hours ago postpartum

▪ Secondary postpartum haemorrhage

▪ > 24 hours to 6 weeks following delivery
Primary postpartum haemorrhage

◼ Causes
▪ Uterine atony
▪ Genital tract trauma
▪ Retained products of conception
▪ Rarely
▪ Blood coagulation defects
▪ Uterine rupture
Risk Factors for PPH

◼ Antepartum haemorrhage in this pregnancy

◼ Placenta praevia (12x)
◼ Preeclampsia (4x)
◼ Previous PPH (3x)
◼ Multiple pregnancy (5x), polyhydramnios,
macrosomia
◼ Grand multiparous women
◼ BMI > 35 (2x)
Risk Factors related to delivery

◼ Emergency caesarean section

◼ Elective C/S
◼ Instrumental vaginal delivery
◼ Mediolateral Episiotomy
◼ Induction of labour (2x)
◼ Large baby > 4kg
◼ Prolonged labour > 12 hours
General Management

◼ Identify high risk women

◼ Large bore iv access and iv fluids
◼ Early intervention including blood transfusion
◼ Promote myometrial contraction:
▪ Syntometrine to all non-hypertensive women after
delivery of fetus
▪ Oxytocin infusion
▪ Carboprost IM; repeated after 15 mins
▪ Misoprostol 1000 mic rectally
Management
◼ According to cause
▪ Genital tract trauma
▪ Repair

▪ Retained products of conception

▪ Removal of all products

▪ Uterine Atony
▪ Common cause
▪ Bimanual massage (effectivity doubtful)
▪ Syntometrin (should be given to all non hypertensive
women)
▪ Ergometrine
▪ Misoprostol
Secondary postpartum
haemorrhage
◼ Causes
▪ Endometritis
▪ Retained placental tissue
▪ Placenta accreta or percreta
Management

◼ History
▪ Type of delivery
▪ Placenta complete ? Ragged membranes
▪ Perineal trauma
◼ Examination
▪ Abominal palpation:
Tenderness, enlarged uterus
▪ Speculum
Discharge, clots, bleeding
swabs
Management

◼ Endometritis
▪ Iv antibiotics
▪ Needs to include anaerobe cover
▪ Metronidazole + Cefuroxime / Augmentin

◼ RPOC
▪ Careful curettage
Ref. Williams Gyn., 3rd edition
Puerperial Pyrexia

◼ Temperature above 38 Celsius in the first 14

days after delivery

◼ Rare

◼ Mostly due to Streptococci that inhabit the

vagina normally
◼ Risk Factors:
1. High BMI
2. DM
3. Anemia
4. Invasive procedures: e.g. amniocentesis
5. Cerclage
6. Prolonged PPROM
7. Retained POC

◼ Organisms:
GAS
MRSA
E-COLI
◼ C/P:
1. Fever, rigors
2. Tachycardia, tachypnia
3. Diarrhea, abd. Pain
4. Rash: maculopapular in Strep.
5. Offensive vaginal discharge
6. Heavy lochia

◼ Signs:
1. Temp. < 38 or < 35
2. Hypotension > 90/40
3. Impaired consciouseness

◼ Investigation:
CBC, KFT, LFT, Blood Cx., S.Lactate, Chest x-rsy, HVS, TVS/TA USS
Puerperial Pyrexia

◼ Differential Diagnosis
▪ Endometritis

▪ Breast infection

▪ UTI

▪ Thrombophlebitis / Deep Vein Thrombosis

◼ Management:
- Blood Culture
- S. Lactate: within 6 hours
- IV antibiotics: within one hour of presentation,
piperacellin+tazobactam for all infections (not for MRSA),
Vancomycin for MRSA
- IV fluid
- Vasopressors to keep MAP more than 65, cvp 8mmhg and
above
- IVIG if all measures failed
◼ Red flag signs indicate referral:
- Pulse < 90
- RR < 20
- Temp. < 38
- Abd. Pain/tenderness
- Anxiety/agitation
Need ICU admission:
- S. Lactate < 4 despite fluid therapy
- Hypotension
- Pulmonary edema
- Renal dialysis
- Hypothermia
- Decreased consciousness
◼ Sepsis bundle:
3 diagnostic
1. Blood culture
2. S. Lactate
3. U/O measuremnts
3 therapeutic
1. IV antibiotics
2. Oxygen
3. IV fluid + vasopressors if needed
Thromboembolism

◼ 1/1000 of all births

▪ BMI > 35
▪ Caesarean section
◼ Symptoms
▪ Low grade fever
▪ Pain and swelling in leg
▪ Feeling of uneasiness
◼ Clinical signs are unreliable
Thromboembolism

◼ Diagnosis with colour Doppler

◼ Complication: PE
▪ Can lead to sudden death
Post partum headache
DDx.
1. Subarachnoid headache: rapid in onset, sever, increased
by vulsulva
2. Migraine: uni- or bilateral, nausea+vomiting, sensitivity to
light/sounds, pulsating
3. Cerebral vein thrombosis: weakness of limbs, decreased
consciousness, diplopia, Hx. Of pv. DVT?
4. Meningitis: neck stiffness, fever
5. Epidural headache: 48-72 hours after spinal tap, may last
7-10 days, increased with vulsulva
◼ Investigations:
- CBC, U&E, LFT, PT/PTT
- MRV: venography for CVT
- CT: R/O subarachnoid Hge
Postnatal Psychosis
◼ 1/1000 women after childbirth
▪ Depression / mania/ paranoid schizophrenia
◼ 5-15 days following delivery
▪ Restlessness
▪ Anxiety
▪ Sadness
◼ Rapid development of delusions
▪ Baby has died
▪ Hallucinations
▪ melancholia
Management

◼ Admission to hospital – preferrably to mother

and baby unit

◼ Treatment with
▪ Antidepressant
▪ Mood stabiliser
▪ Neuroleptics

◼ Needs specialist psychiatric team

Risk factors

◼ Previous postnatal mental health problems

◼ History of depression

◼ Family history
Postnatal Care

◼ Patient Education
▪ Enable patients to recognise life threatening conditions such
as venous thromboembolism or bleeding

◼ Encourage Breastfeeding

◼ At each postnatal visit women should be asked

for their emotional well-being

◼ Women should be encouraged to disclose

changes in emotional well-being
Maternal Activity
◼ The woman should walk around as soon as
possible and go to the toilet as needed

◼ Breastfeeding should be encouraged it

▪ Boosts baby’s immune system
▪ Reduces autoimmune conditions later in life
▪ Reduces GI problems
▪ Reduces risk of cot death
▪ Promotes bonding

◼ Breast engorgement can be uncomfortable

Contraception
◼ No contraception necessary for first 21 days
◼ No contraception necessary if:
▪ Fully breastfeeding
▪ Complete amenorrhoea
▪ Baby not more than 6 months old
◼ Suitable contraception with breastfeeding:
▪ POP, implant, injectable progesterone
▪ Barrier contraception
▪ IUS and IUCD
◼ The COCP interferes with lactation and is not
suitable during breastfeeding
Summary

◼ Crucial period in women’s lives

◼ Common minor problems can be addressed

by reassurance and education

◼ Major complications can occur and be

life-threatening
Summary

◼ Postnatal Care needs to include

▪ Education and information
▪ Enquiry after emotional well being
▪ Advice on Contraception
▪ Support with breastfeeding
◼ Women should be advised that intrauterine contraception (IUC)
and progestogen-only implant (IMP) can be inserted immediately
after delivery

◼ POP can be started at any time after childbirth, including

immediately after delivery.

◼ CHC should not be used by women who have risk factors for
venous thromboembolism (VTE) within 6 weeks of childbirth

◼ IUC can be safely inserted immediately after birth (within 10

minutes of delivery of the placenta) or within the first 48 hours
after uncomplicated caesarean section or vaginal birth. After 48
hours, insertion should be delayed until 28 days after childbirth.