NORMAL PUERPERIUM

ABNORMALITIES OF THE PUERPERIUM

➢Puerperal Pyrexia
➢Puerperal Sepsis
➢Subinvolution
➢Urinary complications: UTI, Urinary
Retention, Urinary Incontinence, Urinary
Suppression
➢Breast Complications: Breast Engorgement,
Cracked & Retracted Nipple, Acute Mastitis
➢Puerperal Venous Thrombosis & Pulmonary
Embolism
➢Puerperal Emergencies, Obstetric palsies,
Psychiatric Disorders during puerperium
PUERPERAL PYREXIA
 PUERPERAL PYREXIA
“ A rise of temperature reaching 100.4
degree F or more (Measured orally) on
two seperate occassions at 24 hours
apart (excluding first 24 hours) within
first 10 days following delivery is called
Puerperal pyrexia”
➢In some countries postabortal fever
is also included.
CAUSES:-

Pulmonary
infection

Infection:
LSCS
wound
 PUERPERAL SEPSIS
“An infection of the genital tract which
occurs as a complication of delivery
is termed puerperal sepsis.”

➢Puerperal pyrexia is considered to

be due to genital tract infection unless
proved otherwise.
 INCEDENCE
❖There had been marked decline in
puerperal sepsis during the past few years
due to:-

Improved obstetric care

Availability of wider range of

antibiotics
CAUSES:-

Combination of
all called as
Pelvic Cellulitis
 PREDISPOSING FACTORS
➢Damage of Cervicovaginal
mucous membrane
➢Large placental wound surface
area
➢Blood clots presents at placental
site
ANTEPARTUM FACTORS:
✓Malnutrition and anemia
✓Preterm labour
✓PROM
 INTRAPARTUM FACTORS:
✓Repeated vaginal examinations
✓Prolonged rupture of membranes
✓Dehydration and keto- acidosis during
labour
✓Traumatic operative delivery
✓Hemorrhage
✓Retained bits of placenta or
membranes
✓Placenta previa
✓Cesarean Section delivery
MICRO-ORGANISMS RESPONSIBLE
FOR PUERPERL SEPSIS
AEROBIC:-
▪ Streptococcus hemolytic group- A
▪ Streptococcus hemolytic group - B
▪Others: Streptococcus pyogenus, aureus,
E coli, Pseudomonas, chlamydia

ANAEROBIC:-
▪ Streptococcus, peptococcus, bacteriodes
MODE OF INFECTION
➢Puerperal sepsis is essentially a
wound infection
➢Placental site, lacerations of the
genital tract or cesarean section
wounds
➢It may get infected by
ENDOGENOUS or EXOGENOUS
organisms.
CLINICAL FEATURES:-
1. LOCAL INFECTION
✓Slight temperature rise
✓Generalized malaise
✓Headache
✓Redness and swelling to local wound
✓Pus formation
2. UTERINE INFECTION
MILD:-
▪ Rise in temperature and pulse rate
▪ Offensive and copious lochial discharge
▪ Subinvoluted and tender uterus
SEVERE:-
▪Acute onset with high grade temperature
with chills and rigor
▪ Rapid pulse rate
▪ Scanty and orderless lochia
3. SPREADING INFECTION
❑Parametritis

❑Pelvic pritonitis

❑General peritonitis

❑Thrombophlebitis

❑Septicemia
 INVESTIGATION
History, Clinical examination

High vaginal endocervical swab

Blood examination

Pelvic ultrasound

CT scan, MRI
PROPHYLAXIS
ANTENATAL:
✓Improvement of nutritional status
✓Eradication of any septic status

INTRANATAL:
✓Full surgical asepsis during labour
✓Prophylactic antibiotics: Cefriaxone 1g IV
immediate after cord clamping and second
dose: after 8 hour is recommended
POSTNATAL:
✓Aseptic precautions atleast one
week following delivery
✓Too many visitors are restricted
✓Sterilized senitory pads are to be
used
✓Infected babies and mothers should be
in isolated room
 TREATMENT
GENERAL CARE:-
➢Isolation of the patient

➢Adequate fluid and calorie (IV)

➢Anemia is to be corrected

➢Progress chart should be

maintained
ANTIBIOTICS
ANTIBIOTICS
➢Gentamicin, 2 mg/kg IV loading dose
followed by 1.5 mg/kg IV every 8
hours
➢Ampicillin, 1g IV every 6 hours
➢Clindamycin 900 mg, IV every 8
hours
➢Cefotaxime 1 g, 8 hourly IV is an
alternative
➢Metrinidazole 0.5 g IV, 8 hourly
SURGICAL TREATMENT
SURGICAL TREATMENT
PERINEAL WOUND:-
❑Stiches of perineal wound may have to
be removed to facilitate drainage of pus
and relieve pain
❑Wound has to be cleaned with sitz bath
several times per day and dressed with
antiseptic ointment or powder
❑After the infection is controlled,
secondary suture may be given on later
date
RETAINED UTERINE PRODUCTS:-
❑With diameter of 3 cm or less may be
disregarded or left alone
❑Otherwise surgical evacuation after
antibiotic coverage for 24 hours should be
done to avoid risk of septicemia

SEPTIC THROMBOPHLEBITIS:-
❑IV Heparin for 7-10 days
PELVIC ABCESS:-
❑Drainage by colpotomy under ultrasound
guidance

WOUND DEHISCENCE:
➢Dehiscence of episiotomy or abdominal wound
following cesarean section:-
❑Scrubbing the wound

❑Debridement of all necrotic tissues

❑Secondary suture
LAPROTOMY:
✓Has got limited indications
✓IV fluids and antibiotics usually controls
the peritonitis
✓When the peritonitis is unresponsible to
antibiotics laprotomy is indicated

HYSTERECTOMY:
✓In case of uterine rupture or perforation
✓Multiple abcess, gangrenous uterus
✓Ruptured tubo-ovarian abcess
NECROTYSING FACITIS:
❑Wound scrubbing
❑Debridement of all necrotic tissues
❑Use of effective antimicrobial agents

BACTEREMIC OR SEPTIC SHOCK:

❑Fluid and electrolyte balance
❑Respiratory supports
❑Circulatory support (dopamine/ dobutamine)
❑Infection control
SUBINVOLUTION
 DEFINITION
➢“When the involution is impaired
or retarded it is called
subinvolution”

➢The uterus is the most common

organ
 CAUSES
PREDISPOSING FACTORS:
➢Grand multipara
➢Over distention of uterus
➢Maternal ill health
➢Cesarean section
➢Prolapse of the uterus
➢Retroversion
➢Uterine fibroid
 CAUSES
AGGREAVATING FACTORS:-
➢Retained products of
conception
➢Uterine sepsis (Endometritis)
 SYMPTOMS
➢May be asymptomatic sometimes

➢Abnormal Lochial Discharge : Excessive or

prolonged

➢Irregular at times Excessive Uterine

Bleeding

➢Irregular Cramp like Pain (Retained bits)

➢Rise of Temperature in case of Sepsis

 SIGNS

Fundal
Displaced
height Uterus feels
Bladder or
Greater than Boggy and
Loaded
Postnatal Softer
Rectum
Day
 MANAGEMENT
✓Antibiotics in case of infection
✓Exploration of uterus for
retained products
✓Pessary in prolapse or
retroversion
✓Methargin to enhance
involution process
 URINARY
COMPLICATIONS IN
PUERPERIUM
URINARY TRACT INFECTION
➢Most common cause of
puerperal pyrexia
➢Incedence 1-5 %
➢May be because of consequences
of: Reccurence of previous cystitis
or pyelitis, asymptomatic bacteriuria
➢First time because of:
Frequent catheterization,
stasis of urine
ORGANISMS RESPONSIBLE:-

Strepto
coccal

aureus
CLINICAL FETURES:

Acute
Fever pain

Pus,
blood Burning
clots in miturition
urine
MANAGEMENT:

IV
fluids
 RETENTION OF URINE
Common complication in early
puerperium.

CAUSES:
❖Bruising
❖Edema of bladder neck
❖Reflex from the perineal
injury
❖Anaccustamized position
 TREATMENT
✓Indwelling catheter for 48 hours
✓Following removal catheter
recidual urine is to be measured
✓If it is more than 100 ml drainage
is resumed
✓Appropriate urinary antiseptics up to
5- 7 days
 INCONTENENCE OF URINE
➢Not a common symptom following
birth

It may be:-
✓Stress incontenence (late puerperium)
✓overflow incontenence
( following retention of urine)
✓True incontenence (soon following
labour)
 SUPRESSION OF URINE
➢“If the 24 hours urine excretion is
less than 400 ml or less, supression of
urine is dagnosed.”
➢The cause is to be sought for and
appropriate management is instituted.
 BREAST
COMPLICATIONS
COMMON COMPLICATIONS

Breast engorgement

Cracked and inverted nipple

Mastitis and breast abcess

Lactation failure
 BREAST ENGORGEMENT
➢Breast engorgement is due to
exaggerated normal venous and
lymphatic engorgement of the breasts
which precedes lactation.
➢This in turn prevents escape of
milk from the lacteal system
➢The primiparous patient and the
patient with inelastic breasts are more
likely develop breast engorgement
➢Engorgement is an indication that
the baby is not in step with stage of
lactation
ONSET:
• It usually manifests after the milk
secretion starts ( 3rd and 4th day
postpartm)
 SYMPTOMS:

Considerable
pain and
feeling of
tendernes or
heaviness Generalized
malaise
Rise of
temperature

Painful
breast
feeding
PREVENTION:

❑Avoid prelecteal feeds

❑Initiate early breast feeding
❑Exclusive breast feeding on demand
❑Feeding in correct position
TREATMENT:

❑Support with the binders

❑Mannual expression of milk
❑Administer analgesics for pain
❑Frequently and regular feeding the
baby
❑In severe cases gentle use of breast
pump
❑Hot application
 CRACKED AND RETRACTED
NIPPLE

The nipple may become painful due to:

CAUSES:-
 SYMPTOMS

➢Condition may remain asymptomatic

➢Sometimes painful when feeding
the baby
➢When infected, the infection may
spread to the deeper tissue proceding
mastitis
 PROPHYLAXIS

❑Local cleanliness during pregnancy

and puerperium
❑Clean the crusts before and
after feeding
❑Application of lotion to soothen
the epithelium
 TREATMENT
✓Correct attachement during feeding
✓Purified lanonin with mother's milk
applied 3 or 4 times a day for healing
✓In severe
cases
expression of
milk by
breast pump
✓For inflammed
nipple and areola
miconazole
lotion is applied
✓Apply
nipple
shields
✓If persistant...
biopsy is needed
 RETRACTED AND FLAT NIPPLE
➢Commonly seen in primiparous
mother

➢Manual expression of milk is initiated

❖Correction of retracted nipple

 ACUTE MASTITIS
➢Incidence of mastitis is 2-5 %
in lactating
➢Less than 1% in nonlactating
mother

Organisms involved are...

▪ Streptococcus aureus,
▪ S. epidermidis and
▪ Streptococci viridans
Mode of infection:-

Two different types of mastitis based on

location of infection.
1.Infection that involves the breast
paranchymal tissues leading to cellulitis.
(lacteal system remains unaffected)
2.Infection up to lactefarous ducts...lead
to development of primary mammary
adenitis
Source of infection : infant's nose/mouth
➢Noninfected mastitis is due to
milk stasis.
➢Feeding from the affected breast
can solve the problem

ONSET:
❖In superficial cellulitis, onset is acute
during first 2-4 weeks postpartum
❖However it may occurs after several
weeks also
 CLINICAL FEATURES
SYMPTOM
S
INCLUDE:
✓Generalize
d malaise
and
headache
✓Fever
( 102
degree F)
 CLINICAL FEATURES
SIGNS INCLUDE:
✓Presence of toxic features
✓Redness of overlying skin and swelling
✓Warm and flushy
 COMPLICATION

➢Due to variable distruction of breast

tissues, it leads to the formation of
a breast abcess.
 PROPHYLAXIS
➢Hand washing before and after each
feed, maintaing hygiene, keep the breast
and nipple dry
 MANAGEMENT
❑Support by binders
❑Plenty of oral fluids
❑Good attachment when feeding
the baby
❑Initiate feeding from uninfected breast
first to establish let down
❑The infected site is emptied manually
with each feed
❑Dicloxacilin is the drug of choice. 500
mg 6 hourly. erythromycin is
• Antibiotic therapy is to continue up to 7
days
• Analgesics
• Milk flow is maintained by feeding the
baby
• It will prevent proloferation of
staphylococcus in the stagnant milk
• The ingested staphylococcus will
digested without any harm
 BREAST ABCESS
FEATURES ARE:
✓Flushed breasts not responding
to antibiotics
✓Browny edema on the overlying
skin
✓Marked tenderness with
fluctuation
✓Swinging temperature
 MANAGEMENT
❑Incision and drainage under general
anesthesia
❑Deep radial incision extending
from near the areolar margin to
prevent injury of the lacteferous
ducts
❑Incision perpendicular to the
lactiferous duct can increase the risk of
fistula formation and ductal occlusion
❑Finger exploration has to be done
to break the walls of loculi.
❑The cavilty is loosely packed with
gause which should be replaced after
24 hoursby a smaller pack
❑Continue till it heals up
❑Abcess can also be drained by serial
percutaneous niddle aspiration under
ultrasound guidance
❑Surgical draiange is commonly done
❑Breast feeding is contonued
at uninvolved side
❑The infected side is mechanically
expressed by pump every two hourly
and with every let down
❑Reccurence risk is about 10 %
❑Once cellulitis resolved breast feeding
from the involved side may be resumed
 BREAST PAIN
May be due to....
✓Engorgement
✓Infection ( candida albicans)
✓Nipple trauma
✓Mastitis
✓Occasionally on letching-on or
let down reflex
 MANAGEMENT
❑Appropriate nursing technique
❑Positioning
❑Breast care
❑Use of myconazole oral lotion or gel
on the nipples and in infant's mouth
thrice daily for two weeks are helpful
 LACTATION FAILURE
CAUSES ARE:
➢Infrequent suckling
➢Depression or anxiety state in
puerperium
➢Unwilling to nursing
➢Ill development of nipples
➢Endogenous supression of prolactin
➢Prolactin inhibition
 MANAGEMENT
ANTENATAL:
❑Counsell mother regading benefits of
nursing her baby
❑To take care of any breast abnormality..
breast engorgement
❑Maintaining adequate breast hygiene
specially in last two months of
pregnancy
PUERPERIUM:
➢Encourage adequate fluid intake
➢To nurse the baby regularly
➢Treat the painfull local lesions to
prevent nursing phobia
➢Metoclopramide 10 g thrice daily,
intranasal oxytocin and sulpiride
( selective dopamine intagonist) has
been found to increase milk production.
➢They act by stimulating
prolactin secretion
PULMONARY
VENOUS
THROMBOSIS
 PREVALENCE

Thrombosis of leg
vein and pelvic vein
is most common

However, the
prevalence is less
 RISK FACTORS
Vascular stasis
Hypercoagulopathy of blood
Vascular endothelial trauma
Other pregnancy related factors
Venous thrombo-embolic disease like..
deep vein thrombosis, thrombophlebitis,
pulmonary embolism
 This stasis causes damage to the
endothelial cells

Thrombophilias are hypercoaguable states

in pregnancy that increase the risk of
venous thrombosis (inheritate/ acquired)
OTHER ACQUIRED RISK FACTORS

Advanced age and

parity
Operative delivery
Obesity
Anemia
Heart disease
Infection- pevic celluitis
Trauma to the venous
wall
Immobility and smoking
 DEEP VEIN THROMBOSIS
➢Clinical diagnosis is unreliable.
➢In majority it remains asymptomatic

SYMPTOMS INCLUDE:
✓Pain in the caff muscles
✓On examination asymmentric
leg edema
✓A positive Homan's sign
 INVESTIGATIONS
▪ Doppler utrasound
▪ VUS- venous utrasonography
▪ Venography
▪ MRI
PELVIC THROMBOPHLEBITIS
➢Originates in the thrombosed veins
at placental site by organism such as
an anaerobic streptococci or
bacteriosides
➢When localised in the pelvis
called pelvic thrombophlebitis.
➢There is specific features but it is
suspected when there is constatnt
fever instead of antibiotics
administration
 EXTRA PELVIC SPREAD
➢Through the right ovarian vein to
inferior vana cava and hence to the
lungs
➢Through left ovarian vein to left
renal vein and hence to the left
kidney
➢Retrograde extension to iliofemoral
veins to produce the clinical
pathological entity called “phlegmasia
alba dolens” ( adjacent cellulitis in
CLINICAL FEATURES:

✓Usually develops in second week of

puerperium
✓Mild pyrexia
✓High grade fever with chills and
rigor
✓Constitutional disturbances like...
headache, malaise, rising pulse rate
✓Swelling, pain, white , cold over
affected leg
 PROPHYLAXIS
PREVENTIVE MEASURES:
❑Prevention of trauma, sepsis, anemia,
dehydration
❑Use of elastic compression stocking
❑Leg exercise, Early ambulation
 MANAGEMENT
❑Bed rest with foot end kept higher
to heart level
❑Pain management
❑Antibiotics
❑Anticoagulants- Heparin- 15000 units IV
followed by 10,000 units 6-8 hourly for
4 to 6 injections. up to 7 to 10 days
❑Administartion of fibrinolytic agents
❑Venous thrombectomy
 PULMONARY EMBOLISM
➢Most leading cause of maternal
deaths
➢Classical symptoms of
massive pulmonary embolism
are...
✓Sudden collapse
✓Acute chest pain
✓Air hunger
✓Death usually occurs within short time
from shock and vagal inhibition
 Important signs...
▪ Tachypnea
▪ Dyspnea
▪ Pleuritis- chest pain
▪ Cough
▪ Tachycardia
▪ Hemoptysis
▪ Rise in temperature
 DIAGNOSIS
➢ECG
➢Arterial blood gas
➢D-Dimer: value (More than 500 ng/ mL)
➢Doppler utrasound
➢Lung scans
➢Pulmonary angiography
➢Spital CT
➢MRA: Magnetic resonance
angiography
 MANAGEMENT
❑Prophylactic measures
❑Active treatment:
✓Resuscitation: cardiac massage, oxygen
therapy, heparin bolus IVof 5000 units and
morphine 15 mg
✓IV fluids
✓Incase of recurrent .. embolectomy,
placement of caval filters, ligation of inferior
vana cava and ovarian veins
 OBSTETRIC PALSIES
(Syn.POSTPARTUM TRAUMATIC NEURITIS)

➢The commonest form of obstetric

palsy encountered in puerperium is...
“FOOT DROP”
➢Usually unilateral
➢Appears shortly after delivery/ first
day postpartum
➢It is due to stretching of the
lumbosacral trunk by the prolapsed
intervertebral disc between L5 and
S1
➢Backward rotation of the
sacrum during labour may also
be a contributory factor
➢Direct pressure either by fetal head
or forcep blade on the lumbosacral
cord or sacral plexus
➢Condition is usually mild
➢May passed unnoticed
➢Neurological examination reveals
lower motor neurone type of lesions
with placcidity and wasting of muscles
in areas supplied by femoral nerve or
lumbosacral plexus
➢Secondary loss is always present
➢Management of damaged
lumbosacral nerve roots is same as
that of the proplapsed intervertebral
disc in
consultation with an orthopedist
➢Paraplegia due to epidural
hematoma or abcess is rare.
 PUERPERAL
EMERGENCIES
➢There are many acute
complications
➢Majority of them are
alarming complications
➢Arises immediately after
delivery
➢Except pulmonary embolism
Common complications are.....
❑ IMMEDIATE:
–Postpartum hemorrhage

–Shock

–Postpartum eclapmsia

–Pulmonary embolism

–Inversion
❑ EARLY (WITHIN A WEEK):
–Acute retention of urine

–Urinary tract infection

–Puerperal sepsis

–Breast engorgement

–Mastitis and breast abcess

–Pulmonary infection

–Anuria following abruptio placenta,

❑ DELAYED:
–Secondary postpartum hemorrhage

–Thrombo-embolic manifestation

–Psychosis

–Postpartum cardiopathy

–Postpartum hemolytic uremic

syndrome
PSYCHIATRIC DISORDERS
DURING PUERPERIUM
 INTRODUCTION
➢In the first 3 months after delivery,
the incidence of mental illness is
high.
➢Overall incidence is about 15-20%.
➢Sleep deprivation, hormone elevation
near the end of gestation and massive
postpartum withdrawal contribute to
the high risk
 HIGH RISK FACTORS
❖PAST HISTORY:
✓Psychiatric illness
✓Puerperal psychiatric illness

❖FAMILY HISTORY:
✓Major psychiatric illness
✓Marital conflicts
✓Poor social situation
❖PRESENT PREGNANCY:
✓Young age
✓Cesarean delivery
✓Difficult labour
✓Neonatal complications

❖OTHERS:
✓Unmet expectations
 PUERPERAL BLUES
➢It is transient state of mental
illness observed 4-5 days after
delivery
➢Lasts for few days
➢Incidence is 50 %
❖MANIFESTATIONS ARE:
▪ Depression
▪ Anxiety
▪ Tearfullness
▪ Insomnia
▪ Helplessness
▪ Negative feelings towards the infant
▪ No specific metabolic or endocrine
abnormalities detected
▪ But lowered troptophan (neurotransmitor
serotonin) level is observed. it indicats
altered neurotransmitter function
❖TREATMENT:
❑Reassurance

❑Psychological support by the family

members
POSTPARTUM DEPRESSION
➢Observed in 10-20 % of mothers
➢More gradual in onset over the first 4-
6 months following delivery or
abortion
➢Changes in the hypothelamo-
pitutary- adrenal axis may be a cause
MANIFESTED BY:
✓Loss of energy
✓Loss of appetite
✓Insomnia
✓Social withdrawal
✓Irritability
✓Suicidal attitude
✓Risk of reccurence is 50-100%
in subsequence pregnancies
TREATMENT:
❑Is started early
❑Fluoxentine or paroxetine (serotonin
uptake inhibitors)
❑General supportive measures
 POSTPARTUM PSYCHOSIS
➢Observed in 0.14-0.26 % of mothers
➢Commonly seen in women with
past history and family history
➢Onset is relatively sudden
➢Lasts for 4 days
MANIFESTED BY:
✓Fear
✓Restlessness
✓Confusion followed by hallucination,
delusion and disorientation
✓Suicidal, infanticidal impulses
✓Temporary seperation and clinical
supervision is needed
✓Risk foe reccurence 20-25%
MANAGEMENT:
❑A psychiatrist must be consulted urgently
❑Hospitalization is needed
❑Chlopramazine 150 mg stat and 50-150 mg
three time /day is started
❑Sublingual estradiol 1 mg TDS in
significant improvement
❑Electro convulsive therapy if remains
unresponsive or in depressive psychosis
❑Lithium in manic depressive psychosis
❑Breast feeding is restricted in case of
lithium administration
 PSYCHOLOGICAL RESPONSES TO THE
PERINATAL DEATHS AND MANAGEMENT

➢Most perinatal events are joyful

➢But when a fetal /neonatal death
occurs, social attention must be given
to grieving parents and family
➢It may be because of unexcpected
hysterectomy, birth of malformed or
chronically ill infant
➢Prolonged seperation from
chronically ill infant can also cause
grief
➢Physician, nurse and attending
staff must understand patient's
reaction
➢The common maternal
somatic symptoms are...
✓Insomnnia
✓Fatigue
✓Sighing respiration
✓Feeling of guilt
✓Anger
✓Hostility ( feeling of opposition)
MANAGEMENT OF PERINATAL GRIEVING

❑Facilitating grieving process with

consolation (comfort), support, sympathy
❑Others are:
1. supporting the couple in seeing/ holding/
taking photographs of infant
2. Autopsy requests
3. Planning investigations
4. Follow up visits
5. Plan for subsequent pregnancy