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 .
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