ABNORMALITIES OF

PUERPERIUM
BY:NAMUJJA MARIA NATASHA
2021-08-05272
SUPERVISOR: DR.OKELLO JAMES
 NORMAL PUERPERIUM
• Defn.
Puerperium is the period following childbirth during
which the body tissues, especially the pelvic organs
revert back to pre- pregnancy state, both
anatomically and physiologically.
 Duration: 6weeks( 42 days)
 Divided into: immediate-within 24hrs
early-up to 7 days
remote-up to the 6th week
 Examples of abnormalities of
puerperim
• Puerperal pyrexia
• Puerperal sepsis
• Sub involution
• Urinary complications: uti, urinary retention,
urinary incontinence, urinary suppression
• Breast complications: breast engorgement,
cracked and retracted nipple, acute mastitis
• Obstetric palsies
• Psychotic disorders during puerperium
 Puerperal pyrexia
• This is a rise of temperature, which is greater
than or equal to 38 degree C /100.4 degree F(
measured orally) on two separate occasions at 24hrs
apart within the first 10 days following delivery.
 causes
• Puerperal sepsis
• Urinary tract infection
• Mastitis
• Pulmonary infection
• infection: LSCS wound
• Unknown origin
Puerperal sepsis
 definition

• Puerperal sepsis is the infection of the genital

tract at any time between the birth of the
baby to the forty-second day following
delivery or post-abortion.
 Prevalence
In Uganda prevalence of puerperal sepsis is
about 7.6% and considered as the greatest
burden experienced in low income countries
(WHO, 2006).
 Predisposing factors
Antepartum Intrapartum
• Malnutrition • dehydration
• Diabetes • Repeated vaginal
• Obesity examinations
• Pretermlabour • Retained placenta bit
• Early rupture of • Caesarean section
membranes delivery
 causes
• Endometritis
h
• Endomyeometritis
• Endoparametritis
A combination of all is called pelvic cellulitis
 Micro-organisms responsible for
puerperal sepsis
Aerobic
• Streptococcus hemolytic group –B
• Streptococcus hemolytic group-A
• others: Streptococcus pyogenes, E.coli,
chlamydia, pseudomonas
Anerobic
• bacteriodes, staphylococcus,peptococcus
 Signs and symptoms

Puerperal sepsis is characterized by:

• Temperature> 38°C
• Tachycardia
• Lower abdominal pain
• Sub-involuted uterus
• Foul-smelling lochia
• Pus discharge from the vagina
• Laboratory examination of discharge will
reveal causative bacteria
 investigations
• History taking and clinical examination
• Swabs: from genital tract - high vaginal swab; and/or
from the wound
• Urinalysis: Chemistry (Urine dipstick), Microscopy,
culture and sensitivity
• blood examination:
- Complete blood count (CBC)
- Culture and sensitivity in severe cases
- Blood grouping and cross-matching in severe
anemic cases
• pelvic ultrasound
• CT scan or MRI
 Treatment if dehydrated or in shock

• Assess general condition.

• Record vital signs
• Give IV fluids (dextrose or normal
saline).
• Start broad-spectrum antibiotics
IV ampicillin 500mg 6hourly
IV Gentamycin 80mg 12 hourly
IV Metronidazole 500mg 8hourly for 3
days
NOTE:
• Give the above combination of antibiotics until the
woman is fever-free for 48 hours.
• The antibiotics are usually given for 3days, however, if
fever is still present on the third day continue with
antibiotics until she is fever free for 48 hours
• Oral antibiotics are not necessary after
stopping IV antibiotics
• Give 100 mg hydrocortisone IV 12 hourly
(two doses)
• Transfuse if severely anemic
 Subsequent management

Identify the site of infection and treat

accordingly:
• Remove any retained placenta and
membranes.
• For wound infection: irrigate wound,
surgical debridement, give antibiotics
and re-suture when wound is clean.
Follow-up
• Review after 1 week and then again in 6
weeks or as needed.
• Mother should be advised to abstain from
sexual intercourse for at least 6weeks.
• Counsel on future pregnancies
 Prevention of puerperal sepsis
ANTENATAL
• eradication of any septic status
• improvement of nutrition status
INTRANATAL
• full surgical asepsis during labour
• prophylatic antibiotics: in high risk cases such as preterm rupture of membranes
and during labor
POSTNATAL
• Aseptic practices: Continuing good hygiene practices, including handwashing and
wound care, for both mother and baby is essential.

• Urinary catheter removal: Removing catheters as soon as possible helps prevent

urinary tract infections, a common source of postpartum infections.

• Antibiotic prophylaxis: In certain cases, such as cesarean section or retained

placental fragments, short-term antibiotic prophylaxis may be prescribed
 Subinvolution
• Uterus involution is the process where the
uterus returns to its pre- pregnancy state.
• In primigravidas, uterine involution increases
gradually in the earliest day after delivery (
from 0.95 to 1.6 cm per day (1.2wks)) while in
multiparrous this increasing starts after the 4th
day
• “when the involution is impaired or retarded
its called subinvolution”
 Predisposing factors
• multiparity
• Malnutrition
• obesity
• Chronic medical illnesses such as diabetes
• Caesarean section
• prolapse of the uterus
• Uterine fibroid
• Retained placental bits
 Symptoms and signs
• Irregular cramp like pain
• Rise in temperature incase of sepsis
• Abnormal lochial discharge: excessive or
prolonged
• Irregular uterine bleedingFundal height
greater than expected on postnatal day
• Displaced bladder
• Uterus feels boggy and softer
 management
• Exploration of uterus for retained products
• Pessary in uterine prolapse
• Methergine to enhance involution process

• Antibiotics in case of an infection

 URINARY COMPLICAIONS IN
PUERPERIUM
1. Urinary tract infections
2. Retention of urine
3. Supression of urine
 1.URINARY TRACT INFECTIONS

• most common cause of puerperal pyrexia

• maybe due to recurrence of previous cystitis
or asymptomatic bacteriuria
• First time because of: frequent catheterizaton,
stasis of urine
 organisms responsible

• E.coli
• Klebsiella
• Proteus
• Streptococcal aureus
 clinical features
• Fever, chills, malaise
• Burning micturition
• Frequency of micturition
• Urgency to urinate
• Lower abdominal pain and tenderness
• Haematuria
 Management

If cystitis give: p.o amoxicillin 500 mg 3 times daily

or p.o Nitrofurantoin 100 mg 8 hourly for 5 days

If pyelonephritis :Obtain a mid-stream specimen of urine (MSSU) and send for chemistry using the urine
dipstick, microscopy and culture and sensitivity if indicated.

• Ensure adequate hydration by oral or IV route.

• Continue with paracetamol for pain and to lower temperature
• Ampicillin 2g IV every 6 hours plus Gentamycin 80mg 8 hourly IV single dose for 7 days.
Once the woman is fever free for 48 hours, give amoxicillin 1g by mouth three times per day
to complete 14 days of treatment

Counseling on the following;

• Encourage frequent intake of oral fluids.
• Counsel on personal hygiene.
• Advise on frequent emptying of the bladder
• Adherence to medication
 Retention of urine
• Common in early puerperium
CAUSES
• bruising
• Edema of bladder neck
• Reflex from peritoneal injury
• Anaccustamized position
 management
• Indwelling catheter for 48hours
• Following removal of catheter residual urine is
to be measured
• If its more than 100mls, drainage is resumed
• appropriate urinary antiseptics up to 5-7 days
Breast complications
 common compictions
• Breast engorgement
• Cracked and inverted nipple
• Mastitis and breast abscess
• Lactation failure
 BREAST ENGORGMENT
• This is due to the exaggerated normal venous
and lymphatic engorgement of the breasts
which precedes lactation.
• This in turn prevents the escape of milk from
the lacteal system
• The primiparous patient and the one with
inelastic breasts are more likely to develop
breast engorgement
• Engorgement is an indication of the baby is
not in step with stage of lactation
ONSET:
• it usually manifests after the milk secretion
starts(3rd and 4th day postpartum)
 symptoms
• Mosiderable painand feelind of heaviness
• Generalised malaise
• Rise of temperature
• Painful breast deedin
 management
• For breastfeeding mothers, advise to empty the breast (manually by
expressing the milk or with breast pump)
• Warm compress and encourage breastfeeding
• If mother is not breastfeeding for example in case of stillbirth,
neonatal death, or by choice, advise her to:
avoid expressing the milk, apply cold compress, or cabbage leaves
as required and wear a firm supporting bra, and give;
- Tablet Ibuprofen 400mg 8 hourly for 3 days
- Bromocriptine* 2.5mg 12 hourly for 14 days
- OR
- Cabergoline 0.5mg 2 tablets as a
stat dose immediately after delivery
to stop the production of breast
milk
 mastitis
• Mastitis is inflammation of the breast
tissue that results in breast pain, swelling,
warmth and redness.
Predisposing factors
• Cracked nipples
• Breast engorgement
• Oral infection in the baby
Differential Diagnosis
• Breast abscess
• Breast engorgement
 investigations
In severe cases only:
• Culture of breast milk
• Complete Blood Count (CBC) for white
blood count
 management
• Counsel and reassure the mother.
• Encourage breastfeeding on the unaffected
breast.
• Demonstrate proper position and breast
attachment
• Place warm compress over the breast before
breastfeeding to allow free flow of milk.
• Apply cold compress to affected breast after
breastfeeding
• Give antibiotics ( oral flucloxacillin 500mg 8
hourly for 5 days or ampiclox 500 mg 6 hourly
for 5 days,
• Oral analgesia, ibuprofen 400mg 8 hourly for 3
days or paracetamol 1gm 8hourly for 3 days. ).
 Subsequent treatment
If condition does not subside within 48hours, review and treat
according to culture and sensitivity.
• Treat infection in baby’s mouth if present
• Continue breastfeeding to keep breasts empty
• Treat baby’s infection (e.g., oral thrush)
• Educate patient on causes, treatment and best breastfeeding
practices
• Ensure compliance with antibiotic therapy to avoid abscess
formation
 CRAKED / SORE NIPPLES
• Loss of epithelium covering considerable area
of the nipple or a small, deep fissure situated
at either the tip or base of the nipple,
resulting in sore or painful nipples.
 CAUSES
• Improper positioning and attachment of the
baby on the breast
• Baby with oral thrush
• Severe dry skin
• Breast eczema
 DIAGNOSIS
• Take history.
• Perform breast (nipple) examination
 MANAGEMENT
• Counsel and demonstrate to the mother proper positioning
and attachment of the baby on the breast.
• Advise to continue breastfeeding.
• Express some breast milk and apply it around the affected
nipple and leave it exposed.
• Keep nipple clean and moist.
• If crack is deep and painful, rest affected breast but express
the breast milk from it frequently; baby may be fed on this
milk with cup and spoon.
• Provide health education and counselling.
• Give analgesics.
• If severe pain or swelling occurs, manage as mastitis.
 PRECAUTIONS TO TAKE TO AVOID
COMPLICTAIONS

• Start counselling for breastfeeding in antenatal period.

• Initiate early if she chooses breastfeeding
• Avoid infection of breasts by keeping them clean.
• Avoid engorgement by feeding baby on demand.
• Properly position and fix baby to breast (part of areola
should be inside baby’s mouth).
• Treat infection from baby’s mouth (e.g., thrush).
• Ensure complete emptying of the breast after feeding
 Breast abscess
• This is the formation of pus in an already
inflammed breast.
 Signs and symptoms

• Breast pain
• Preceding mastitis or cracked nipples
• Localised fluctuant area of the breast with
shiny overlying skin
• Fever and general malaise
 investigations
• Culture and sensitivity of pus
• Haemoglobin level
• White blood cell count
 1. management
Incision and drainage by a trained person under general anaesthesia.

• Give initial dose of oral antibiotics and continue the full course after I&D
(flucloxacillin 500mg 8 hourly for 5 days or ampiclox 500mg 6 hourly for 5 days)

• Give analgesics, oral ibuprofen 400mg 8 hourly for 3 days

• Continue or change antibiotics according to culture and sensitivity Results.

• Advise to continue frequent breastfeeding from unaffected breast and express milk
from the affected breast (manually or with breast pump).

• Dress the wound as required.

• Provide psychological support.

 Contn.
• Give advice on supportive binder/bra.

• Educate mother on proper care of the baby (e.g., nutrition and hygiene).

• Educate mother on causes and treatment of breast abscess.

• Do not allow stoppage of breastfeeding, even in cases of bilateral abscesses (express

breasts to maintain lactation)

• If the woman is not breastfeeding, assist with suppression of lactation (

avoid nipple stimulation, reduce fluid intake and prescribe bromocriptine 2.5 mg
12hrly for 14 days).

• If the abscess is large, and there are systemic symptoms, refer to the next level
PSYCHIATRIC DISORDERS DURING
PUERPERIUM
– Postpartum depression
– Postpatum psychosis
 Postpatum depression
• It’s strong feelings of sadness, anxiety (worry)
and tiredness that last for a long time after
giving birth.

• In Uganda, over 70 per 300 women suffer

from postpartum depression and most of
these mothers do not seek psychological help
due to lack of confidence and fear of
discrimination
 manifestations
• Loss of energy
• Loss of appetite
• Insomnia
• Social withdrawal
• Sucidal attitude
 management
• Serotonin uptake inhibitors ( fluxetine or
paroxetine)
 Postpaturm psychosis
• Commonly seen in women with past hstory
and family history
• Onset is relatively sudden
• Lasts for 4days
 manifestaion
• Fear
• Confusion followed by hallucination, delusion,
disorienation
• Restlessness
• Suicidal
• Infanticidal impulses
 management
• Hospitalise
• Chlorpromazine 150mg stat,50-150mg tds
• Sublingual estradiol 1mg tds in signficant
improvement
• Lithiumin in manic depressive psychosis
• Breastfeeding is restricted in case of lithium
admnistration