Normal and abnormal puerperium by Dr Yin Moe

NORMAL AND ABNORMAL PUERPERIUM

DR. YIN MOE HANSENIOR LECTURERUCSI UNIVERSITY

04/11/2023 NORMAL AND ABNORMAL PUERPERIUM 2

Definition

• Puerperium – a period from the expulsion of the placenta until 6 – 8 weeks after birth, during which time the uterus and other organs and systems return to their pre pregnant state and lactation is initiated.

• Many changes take place within the first 10 -14 days.

• Role changes


Endocrine changes

• Removal of the placenta alters the physiological state – rapid clearance of hormones from plasma and extra cellular fluid

• HPL disappears by 1-2 days• hCG detected for 2 weeks• Alpha feta protein – several weeks• Oestrogens/progesterone – rapid loss• Ovarian function – low for first 2 weeks


• FSH/LH suppressed during pregnancy remain low for 2 weeks following birth, both in lactating and non lactating women, gradual increase over 6 weeks.

• Tends to be a period of infertility


Placental Site• Dramatic decrease in size brings uterine walls into close

apposition and transforms uterus into hard globular mass.

• This has the effect of applying pressure on the placental site - prevents haemorrhage

• 18cm diameter- 9cm

• Promoted by continual action of oxytocin.


Uterine Involution

Weight of uterus after birth 1 kg 6/52 no longer palpable 6/52 50-60g? Caused by withdrawal of placental hormonesBy day 5 - wt 500gms


Involution – ‘turning inwards’

3 processes

• Ischemia occurs as a result of collapse of blood vessels

• Autolysis is physiological process by which involution of uterus is achieved. Breakdown of intracellular protein by proteolytic & hydrolytic enzymes.

• Phagocytocis – disposes of elastic/fibrous tissue




Endometrium

• Regeneration begin 1-2 days after birth• Differentiation into 2 layers

superficial – barrier to infectionbasal – source of new

endometrium• Regeneration takes approx 2-3 weeks.• Placental site regenerates slowly over 6 -7

weeks


LochiaReflects the process of involution and restorationof the endometrium – characteristic postnatal discharge Mean duration – 21-33 daysShorter in multips and with smaller babies

• Lochia rubra: fresh blood from placenta

• Lochia serosa: brownish pink after 4 days

• Lochia alba: white


Cervix and Vagina• Cervix bruised, swollen, oedematous and little tone.

• By end of 1st week cervix decreased in size, closed by end 2nd week

• Vagina smooth, oedamatous, pouting and blue-ish.

• After 3-4 wks ruggae appear.


• Episitomy• Lacerations• Sexual intercourse

1404/11/2023 NORMAL AND ABNORMAL PUERPERIUM


Cardiovascular Changes• Following birth dramatic changes in haemodilution –

cardiovascular instability.

• Cardiac output elevated for 1-2 hours after birth begins to stabilise after about 10 mins. Decreases until 10th day. Normal by 2 weeks.

• Cardiovascular system reverts to normal in 2 - 4 weeks.

• Days 2 -5 diuresis dissipates the extra cellular fluid, up to 3 Kgs weight loss


Coagulation

• Profound physiological changes in the blood and dramatic changes in coagulation and haemostatic mechanisms.

• Changes protect women from haemorrhage.

• Levels remain high for 10 days

• DVT/PE – increased risk if trauma, sepsis, immobility


Blood Volume Changes

• Decreases rapidly over 24 hours. Increase in haemconcentration, Hb rises.

• By 6-9 weeks returned to normal.


Urinary Tract• 24-48 hours rapid diuresis – decreases plasma

volume of blood to non-pregnant levels.

• High oestrogen augments effects of ADH - increases blood volume

• Larger quantities of nitrogen – autolysis• Trauma to bladder base, oedema


c

• To provide sound family planning information and advice

• To care for and monitor the progress of the mother in the postnatal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the newborn infant

• To examine and care for the newborn infant; to take all initiatives which are necessary in case of need and to carry out immediate resuscitation


PUERPERAL PYREXIA

• A temperature of 38.0°C (100.4°F) or higher, which occurs on any 2 of the first 10 days postpartum, exclusive of the first 24 hours, and which is taken orally by a standard technique at least four times daily. (Joint Committee on Maternal Welfare)

• Some common sites of infection causing puerpural pyrexia– Chest– Throat– Breasts– Urinary tract– Pelvic organs– Wounds – caesarean, perineal


PUERPERAL PYREXIACAUSE DESCRIPTIONGenital tract infection -Tender bulky uterus.

-Prolonged bleeding/pink or discoloured lochia.-Painful inflamed perineum.-Most common infective organisms; Escherichia coli, Group A streptococcus spp., Staphylococcus spp.

Urinary tract infection -Frequency in micturation, painful micturation, haematuria.-Rigors seen in cases of pyelonephritis-Most common infective organisms; Escherichia coli, Proteus spp. and Klebsiella spp.

Mastitis -Painful, hard, red breast abscess-Nipple trauma and cellulitis-Most common infective organism; Staphylococcus spp

Postoperative infection (following Caesarean section)

-high risk of postpartum septicaemia, wound problems and fever-Usual presentation; Painful, red suture line, tenderness on deep palpation, lochia pink/coloured.

Deep venous thrombosis -Caused by venous stasis. -Painful, swollen calf.

Others -Viral infection or chest infection.


PUERPERAL PYREXIA• Causative organisms

– Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria. – Anaerobic organisms include Bacteroides, Peptostreptococcus, Peptococcus, and Clostridium perfringens.


PUERPERAL PYREXIA• Full examination of chest, breasts, legs,

lochia and bimanual vaginal examination should be done.

• Majority of infections originate from the urinary or genital tract.

• Caused by poor sterile technique, delivery with significant manipulation, caesarean birth, or overgrowth of local flora.


1) Post partum haemorrhage (PPH)

• Primary PPH is defined as bleeding from the genital tract of 600 ml or more in the first 24 hours following delivery. Such bleeding usually occurs very unexpectedly due to retained placental tissue or birth canal trauma.

• Secondary PPH - bleeding occurs after the first 24 hours of delivery until the end of the puerperium.


2) Puerperal sepsis:

• It is a fibrile changes occurring during puerperium due to invasion of genital tract by pathogenic bacteria.

Sites of infection:• Wound: mainly the placental site and wounds of the

perineum, vulva, vagina or cervix.Dead tissue: usually blood clots, and retained placental fragment.

Predisposing factors:• General: as anaemia, ante partum hemorrhage, post partum

hemorrhage, malnutrition and toxaemia.• Local: as lacerations, sloughing and premature rupture of the

membrane.


Signs and Symptoms:• Headache, • Raised temperature, • Vomiting, • Dry tongue and lips. • Abdominal examination revealed a supra pubic tenderness

and rigidity. The perineum, vulva, vagina or cervix are become infected and lochia is foul odour.

Treatment:• The primary goal of treatment is concerning the causes and its

predisposing factors for the infection. • At this time lactation and physiotherapy program should be

stopped until fever disappear.


URINARY PROBLEMS• Urinary retention or voiding difficulties may occur postnatally

secondary to painful tears involving the bladder or use of epidurals in labour.

• Retention occurs usually immediately after delivery and is partially due to the sudden decrease in intra abdominal pressure–there is a decreased stretch reflex response following bladder filling.

• Methods that can encourage micturation–early ambulation–pelvic floor exercises–hot baths


URINARY PROBLEMSTrue incontinence occurs rarely but is usually

associated with a vesico-vaginal fistulaAfter surgical repair, the patient is to undergo

physiotherapy to strengthen the pelvic floor muscles.

© Reed Group


THROMBOEMBOLISM• Risk of thromboembolism rises 5 fold during pregnancy & puerperium• Majority of deaths occur in the puerperium• The symptoms and signs of venous thromboembolism:– leg pain and swelling (usually unilateral)– lower abdominal pain– low-grade pyrexia– dyspnoea – chest pain – haemoptysis – Calf muscles are tender and painful on firm palpation.• If DVT & pulmonary embolism is suspected

– bilateral venogram and/or lung scan should be carried out within 24-48 hrs.– full anti-coagulant therapy (heparin) should be started immediately.


PSYCHIATRIC PROBLEMS

• Divided into three conditions based on their severity–”Baby blues” –Postpartum depression–Postpartum psychosis (most severe, may result in suicide/infanticide)

• A syndrome seen among fathers is linked to the mood changes of their wives.–May be due to the added responsibility of having a child and decreased attention from the wife.


PSYCHIATRIC PROBLEMS

• Management–Postpartum blues: no specific treatment other than support

and reassurance from family members and friends.–Postpartum depression: exclude medical causes (eg. thyroid

dysfunction), individual/group psychotherapy for mild cases, medication (antidepressants)/ hospitalization/ electroconvulsive therapy for moderate to severe cases.

–Postpartum psychosis: Inpatient treatment with medication (mood stabilizers-eg. lithium/valproic acid) and/or electroconvulsive therapy.


CHARACTERISTIC “Baby Blues” Postpartum Depression Postpartum Psychosis

Incidence 30%-75% 10%-15% 1%-2%

Time of Onset 3-5 days after delivery Within 3 to 6 months after delivery

Within 8 weeks after delivery

Duration Days to weeks Months to years (if untreated) Months to years (if untreated)

Associated to stressors No Yes, especially lack of support Linked to hormonal changes after delivery

History of mood disorder No association Strong association Strong association

Family history of mood disorder

No association Strong association Strong association

Tearfulness Yes Yes Yes

Mood Lability Yes Often present, but sometimes mood is uniformly depressed

Yes

Anhedonia No Often Yes

Sleep disturbances Sometimes Nearly always Always

Suicidal thoughts No Often Almost always in psychosis stage

Thoughts of harming baby Rarely Often Almost always in psychosis stage

Feelings of guilt, inadequacy Absent or mild Often and excessive Often and excessive


OTHER PROBLEMS• Haemorrhage

Type Timescale Presentation Predisposing factors

Primary haemorrhage

In the first 24 hours

Fresh bleeding, often severelyheavy. Uterus may be soft andpoorly contracted with thefundus still above the umbilicus

Uterine atony [90%]Trauma, vaginal or cervicallacerations, labial tearsCoagulation disorders

Secondaryhaemorrhage

After 24 hours and up to 6 weeks

May be fresh loss or old, altered blood, often malodorous. Theuterus may feel soft, poorlycontracted and possibly tender,with the cervical os open

Retained products ofconceptionEndometritisDysfunctional bleeding


OTHER PROBLEMS

• Bowel problems– Haemorrhoids are a common problem after childbirth, exacerbated by bearing down during the second stage of labour.–Treatment: Local application of 5% lidocaine gel or anusol (hydrocortisone) cream together with bulking agents (eg. Psyllium, fiber) to soften the motions.


OTHER PROBLEMS

• Musculoskeletal problems– Painless divarication (spreading apart) of the recti can occur antenatally due to the enlarging uterus that exerts pressure on the recti, causing them to separate. – Treatment involves exercises that increase muscle tone.


OTHER PROBLEMS• Musculoskeletal problems

– In pregnancy the pelvic ligaments become more lax and the symphysis pubis will separate to some extent. This is beneficial as the anterior-posterior diameter is increased. –In extreme situations the hemi-pelvices can be widely separated causing severe pain making walking difficult. –Treatment: Milder cases: Analgesic and orthopaedic belt

Severe cases: Zimmer frame and bed rest


Total gap width of up to 9mm is normal during pregnancy

Normal non-pregnant pelvis

Abnormal gap is considered to be ≥10mm. Note misalignment.


REFERENCES

• Obstetrics by Ten Teachers, 18th edition• Danforth’s Obstetrics and Gynaecology, 10th

Edition• Obstetrics and Gynecology An Illustrated

Colour Text, 1st Edition• Kaplan and Sadock’s Synopsis of Psychiatry-

Behavioral Sciences/Clinical Psychiatry, 10th Edition

THANK YOU

NORMAL AND ABNORMAL PUERPERIUM

Health & Medicine

Normal and abnormal puerperium by Dr Yin Moe