Puerperium By Prof. dr. A. El-Sharef NUMBER DIRECT CAUSES OF MATERNAL DEATH 35 31 30 23 25 20 12 15 7 10 4 3 3 5 0 CAUSE HAEMORRHAGE PIH UNSAFE ABORTION RUPTURE UTERUS OBSTRUCTED LABOUR PUERPERAL SEPSIS OTHERS puerperium Puerperium o : Is period during which the reproductive organs and all the system of the body returns to their normal condition following the delivery of the placenta and Ends approximately 6 weeks later. puerperium When the endocrine influences of the placenta removed the physiological changes of pregnancy is reversed Puerperium Maternal physiology is well prepared for hemorrhage: increase in blood volume . hypercoagulable state. the “tourniquet” effect of uterine contractions. MECHANISM OF HAEMOSTASIS AFTER DELEVERY • Uterine contraction & retraction • Platelet aggregation clot formation The Principal Changes 1) Uterine Involution : The principal changes Uterine involution : 1. Uterine involution : After the delivery of baby the uterus (myomaterial muscle )is well contracted & retracted and become at the level of the umbilicus , and after 10 – 14 days the uterus well become as pelvic organ. Uterine involution : Breast feeding leading to release of oxytocin from the hypothalamus & posterior pituitary aiding the process of involution & more contraction & retraction of the myomaterial muscle of the uterus and decrease the incidence of post partum hemorrhage Uterine involution At the time of the delivery uterine weight about ( 1 Kg) then after few weeks become 50 -60 gm and shrinks at the process of autolysis . Uterine involution Sub-involution of the uterus this occur when the uterus is not completely contracted & retracted which well leads to post partum hemorrhage and this mostly due to : I. Full bladder Uterine involution II. Retained products of placenta Uterine involution III. Infection at the uterus Uterine involution Para-vaginal haematoma 2 - endometrium The deciduas castes off as result of ischemia and lost as lochial flow . The lochia consists of blood , leucocytes , shreds of deciduas and organisms . The lochia is initially dusky red but this color fades after the first week and the flow usually clears completely within 4 weeks of delivery . The new endometrial will grow from the basal areas of the deciduas but this will influenced by breast feeding. 3- cervix Cervix is very flaccid and curtain –like after delivery but within a few days is returning to the original form and consistency . The cervical channel become closed to a finger during the second week of Puerperium . 4 Vagina The vagina almost , always shows evidence of parity . In the first few days of puerperium , the vaginal walls are smooth , soft and edematous . The distention which has resulted from labor remains for a few days but the return to the normal capacity quit quick . the episiotomies or vaginal and perennial tears healed well provide adequate suturing has been undertaken . Healing may be impaired in the presents of infection or haematoma but even if this happens, healing by granulation is usually occurs. 5 Other systems During the first few days the bladder and urethra may show evidence minor trauma sustained at delivery but don't usually remains in evidence for long . The physiological hydroureter & hydronephrosis will disappears within 6 weeks . there is usually a diuresis during first day of the puerperium and there is fall in plasma volume. 5 Other systems The blood loss at delivery has been normal and should be no anemia and hemoglobin concentration will rise. The levels of blood clotting factors and platelet count rise after delivery . The inhibition of systemic fibrinolytic activity which occurs during pregnancy is reversed within 30 min. of placental delivery . Active mangement 0f 3rd stage of laboure Oxytocics - Routine use in third stage blood loss by 30-40% 10 Units Oxytocin IV bolus Syntometrine 1 Amp IV at the delivery of the anterior shoulder. Ergometrine 1 Amp IV at the delivery of the anterior shoulder. Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM Early cord clamping Active mangement 0f 3rd stage of laboure Inspection of placenta & lower genital tract Management of normal puerperium Management of normal puerperium The majority of mothers are perfectly well during the puerperium and should be encouraged to establish normal activities. Immediately following the delivery of the placenta observation of : Management of normal puerperium 1. Vital signs (P,BP,Temp,R.R) + contraction of the uterus (uterin involution) + Lochia (amount; colure ,and odder) =Every 5 min. for ½ hours , then every ½ hourly for 2 hours, then transfer the mother to the postnatal ward and observation every 2 hours for 6 hourly; then 6 hourly till discharge. Management of normal puerperium 2 ) - Breast examination+lawer limb examination for the detection of signs of DVT every day. 3 ) - The mother should be encouraged to pass urine. Management of normal puerperium 4 ) - Early mobilization. 5 ) - Management of episiotomy ;and perennial tears. 6 ) -In normal delivery the mother can go home 48 hours after delivery ;and 10 days in C.S. 7 ) - Diet regime. 8 ) - postnatal visit. 9 ) - Advising for contraception and spacing of pregnancy. breast feeding Lactation Lactation : In those mothers who breast feed , lactation is the most dominant physiological event of puerperium . • The primary function of breast feeding to continuing of nutrition for newborn . • The secondary function : protection agonist infant infection . Inhibition of ovarian activity . Encouragement of uterine involution . Physiology of lactation The major part of breast development occurs at puberty before the first pregnancy . So , only requires minimal hormonal stimulation for production of milk The skin of the areola is relatively insensitive to tactile stimuli during pregnancy but , much more sensitive immediately after delivery . Breast changes Milk production Two similar independent mechanisms for successful lactation : 1. Prolactin release from A .p mammary glandular tissue stimulation of milk secretion . Prolactin is long chain of polypeptide it has only physiological role that its action on lactating breast . Milk production Prolactin level during lactation depending on the suckling ( strength , frequency and duration ) Prl. release from A.p reaching peak blood level at 30 -45 min. after suckling and returns to the basal level after 2 hour after suckling . Adequate emptying of milk – secretary glands. Milk production Basal prl. Is highest in the immediate puerperium but : In breast feeding decline slowly as suckling declines in later lactation revert to non pregnant levels immediately after weaning ( 54 weeks). In bottle feeding reverted to non pregnant levels immediately after delivery ( 10 weeks ). so prl. appears essential for lactation due to : bromocriptin or dopamine agonist which is so prl. appears essential for lactation due to : bromocriptin or dopamine agonist which is selectively inhibits prl. secretion and decrease milk secretion . Milk production 2 ) – milk ejection reflex ( milk lead down ) mediated by release of oxytocin from hypothalamus and ( p.p ): causing contraction of myoepithelial cells around the milk –secretary . dilatation of main ducts . So , Expelling milk from glands . oxytocin released in response to : suckling , and sensory input like mother seeing or hearing their baby crying . Milk production Highest levels of oxytocin occurring before suckling in response to the baby cry . Milk ejection reflex may be inhibited by emotional stress and maternal anxiety and leads to failure of lactation . So , the key of both mechanisms activated by suckling and mediated through neuroendocrianological pathways . Breast feeding & fertility The key event in lactating amenorrhea is suckling induce changes in the hypothalamic sensitivity to the feed back effects of ovarian hormones . During lactation hypothalamus more sensitive to the negative feedback and less sensitive to the positive feedback . Breast feeding & fertility In bottle feeding : Prl. Returns to level of non pregnant ovarian follicular development ( E2 > 10 micro – gm ). And ovulation occur ( P4 >1 mg ) menstruation by 14 weeks post _ delivery . Breast feeding & fertility In breast feeding : • During first week of suckling ( 60 min./ day ) , the ovarian activity is inhibited and menstruation is suppressed . • At 32 weeks suckling has fallen to 25 min/ day the ovarian follicular activity returns to the normal ( anovulatory cycles ) • At 52 weeks normal ovulatory cycles occurs . • Breast feeding has important contraceptive effect but not absolutely reliable especially after menstruation returns ,and ( 1-10%) of women will conceive during lactation . Complication during breast feeding 1) 2) cracked nipple . Breast engorgement . 3. Acute mastitis 4. Breast abscess drain and with systemic antibiotic Composition of breast milk Comparison to Cow's milk : H.M C. M 75 66 Protein ( g /100 ml) 1.1 3.5 Fat ( g / 1000 ml ) 4.5 3.7 Lactose ( g / 1000ml) 6.8 4.7 7 22 Energy ( Kcl / 1000ml ) Sodium (mcq / L ) contra- indication to breast feeding I. A. o o o o B. 2) Maternal : general disease : H .I .V ( + ve ) Active pulmonary T.B . Heart failure . Chronic nephritis . local : breast abscess and cracked nipples . newborn : sever prematurely and malformation interfere with suckling as cleft – palate . Drugs and breast feeding Some drugs depress milk secretion like : Atropines Estrogens Bromocriptines drugs produce sedation like : Opiates , phenobarbiton , diazepam , chlorohydrate , bromides and large amount of alcohol . Iodides , thioracil , and radioactive iodine can damage thyroids function. BUT (carbimazol is safe ) . Breast feeding is contraindicated if Mother is under treatment of : 1) Alkylating agents . 2) 250 H cholecateiferol . 3) Metronidazol . 4) Lithium . 5) Ergotamins . 6) Antithyriod . 7) Cytotoxin drugs . Complication of puerperium Complication of puerpruim Serious , and sometimes fatal complication arise during puerprium , the most serious complication are : 1) thrombus – embolism ( D. V . T and pulmonary embolism . Complication of puerpruim Deep veins thrombosis and pulmonary embolism is now one of main causes of maternal death and the majority of deaths occur during the puerpuim . Acute DVT present in the superficial femoral vein (arrow). The vein is dilated in the transverse view relative to the adjacent superficial femoral artery, which contains Doppler flow. No flow is present in the vein. Complication of puerpruim 2)Infection . 3) post partum hemorrhage primary & secondary PPH . . . the most common and severe type of obstetric hemorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period. PPH Causes Uterine atony in 70% of cases . c -Retained Placenta -Trauma to birth channel. -Coagulation disorders -Uterine inversion Complication of puerpruim 4)Injury to the birth canal . UTERINE INVERSION Mostly iatrogenic due to mismanagement of rd 3 stage - strong traction on the cord with a relaxed uterus / adherent placenta. Hypertensive disease. Commonest cause of maternal mortality & morbidity about 15-20% of maternal deaths. Hypertensive disease. Eclampsia O.5 per 1000 maternities. Maternal mortality around 1.8%. 35% has major complication. 44% occurs postpartum , 38% ante partum 18% intra partum. Complication of puerpruim 5)Urinary complication . 6)Breast infection Puerperal infection Puerperal pyrexia : which may be due to infection in: respiratory tract infection . pelvic organs( Site of placenta =Endometritis). U. T . I . surgical wounds . breast infection & abscess . thrombo phlebitis . Puerperal pelvic infection Before the introduction of antibiotic , it was the most important cause of maternal death . now rarely results on maternal death and although it can still present as acute life – threatening illness , it more frequently occurs as low – grade infection which causes both immediate and long – term morbidity . It is important that pelvic infection are diagnosed and treated as early as possible . Puerperal pelvic infection Pathology : At delivery , the normal protective barrier agonist infection are temporarily broken down. Puerperal pelvic infection this gives an opportunity for potential pathogens to ascending infection to the decidua and placenta site . spread infection to myomatium , parametrium Fallopian tubes , ovaries ,& peritoneum. Puerperal pelvic infection If virulent infection , the organism reach the peripheral circulation and the patient develops sings of septicemia and end toxic shock . it is more common for the infection to remain localized in the pelvis , and if treatment is not immediate and effective , there is danger of chronic pelvic infection with tubal blockage . Puerperal pelvic infection Predisposing factors : prolonged P. R . M. a protacted labour with multiple vaginal examination . retained products of conception in the uterus . blood clots in the uterus . prolonged labour . Puerperal pelvic infection Organisms : Gram ( + ) : B – hemolytic streptococci is the most virulent Other streptococci & staphylococci may cause acute clinical picture . Gram ( - ): more common to find coliform such as E . Coli or bacteroides fragilis . clostridii . Puerperal pelvic infection Chlamydia : more recently , there has been interest as a cause of pelvic infection . anaerobic infection . difficult to culture . it can cause chronic problems of vaginal discharge , adhesion and tubal blockage . Puerperal pelvic infection Clinical features : Puerperal pyrexia associated with : Offensive lochia. lower abdominal discomfort . In abdominal or bimanual examination : Uterine tenderness aggravated by moving cervix . Swelling beside the uterus or in the pouch of Douglas. Evidence of peritonitis , septicemia and bacteraemic shock , at this stage : patient acutely ill , restless ,dyspnoeic with high swinging Temp. tachycardia , dehydration and have rigors . Puerperal pelvic infection Diagnosis : Made by : clinical grounds . And confirmed by culturing : high vaginal swabs , cervical canal swab urethral swab , and blood culture for aerobic and anaerobic should be taken Puerperal pelvic infection Treatment : after taking swabs for C.S : the initial choice : combined broad spectrum antibiotics ( one of cephalosporins = cephradin 1 gm / 6 hourly ) + metronidazole 500 mg / 6 hourly and this to provides a wide rang of activity agonist Gram (+) and Gram ( -) organisms . The treatment in I .V line for (24- 36 hours) and till response has been achieved . Puerperal pelvic infection When the symptoms are less acute change to the oral route and treatment should continued for at least 10 days . If there is no improvement we should change antibiotic according to the culture and sensitivity. If there is retained placental tissue within uterine cavity, this should be removed under G.A. If there is pelvic abscess should be drainage . Urinary complication The commonest urinary complication in puerperuim is : Urinary injures . Infection . Urinary retention . Urinary incontinence . Urinary retention This is common complication following delivery especially if there is bruising and edema around the bladder base or if there is painful episiotomy wound . sensory stimuli from the bladder are temporarily interrupted and the bladder can be over distended with out discomfort to the patient . this may prevent uterine involution and lead to post –partum hemorrhage . Urinary complication Incontinence of urine : this is an infrequent symptom following childbirth . If incontinuance present it must be established if this so urethral or through a fistula , this need carefully examination . Urinary fistula are uncommon in modern obstetric practice and may be due to : instrumental delivery . neglected obstructed second stage of labour . damaged bladder or ureter as a complication of C .S . Puerperal mental disorders the puerpruim is frequently associated with feeling anxiety and depression and acute psychiatric disorders . THIS IS THE END OF THE LECTUR . HOPE YOU ENJOYED IT ! THANK YOU ! ! !