Abnormal Puerperiu
and Postnatal Care
Purperium
Definition:
It is period about 6-8 weeks following
delivery during which the changes
produced by pregnancy.
Abnormal Puerperium
1.
2.
3.
4.
5.
6.
7.
Puerperal infection ----> retention
UT complication ----> incontinence ----> stress
I true
Thrombo embolism
2nd P.P HE
Subinvloution of the uterus
Foot drop
Mental disorder
Genital Tract Infection:
AE:
1. Predisposing Factors:
1. General
2. Anternatal Factor
Intranatal factor
2. Organism
1. Exogenous
2. Endogenous Streptococci:
Streptococci:
a. B haemolytic strep group A
b. B haemolytic strep group B
C. B haemolytic strep group 0
d. Non-haemolytic streptococci
e. Anaerobic streptococci
Staph:
Staph aureus
Anaerobic staph
Bacilli:
G negative aerobic bacilli
E coli, Klebsiella
G negative anaerobic bacillus
-----> bacteroids
Gm positive anaerobic bacilli
ROUTE OF INFECTION:
Primary Sites: placental site, wound and laceration, clots and pluc.
tissue
Secondary Sites: pelvic cellulitis, thrombophlebitis, pelvic
peritonitis, generalized peritonitis, septicaemia, and septic shock
COMPLICATIONS:
Spread of infection
Renal failure
Death
Secondary infertility
Sheehan
CLINICAL PICTURE --- depends on site of
infection
INVESTIGATIONS:
History
Examination
Special investigations
TREATMENT:
Prophylaxis:
Antenatal, intranatal case, postnatal
Active Treatment:
1.
General treatment
2.
Medical treatment
3.
TTT of complication
----> rest
----> diet
----> fluid
----> antipyretic
----> analgesics
----> antibiotics
Puerperal Pyrexia
Definition:
A rise of temperature above 3SoC
occurring in first 3 weeks of
puerperium persistent at least 2H
hours on recurring within this period.
AE:
Puerperal sepsis
Breast infection
Urinary infection
Episiotomy infection
Wound infection
Other types of infection as respiratory infection,
malaria, gluteal abscess, typhoid
INCIDENCE:
Infection, haemorrhage, hypertension,
disorder remain the most causes of death.
Primary Puerperal Sepsis
Definition:
Genital tract infection after delivery. It is the
commonest cause for puerperal infection.
The causative organism
1. Anaerobic streptococci
2. Group A haemolytic streptococci
3. Staphylococci causing suppurative and pus
4. E. coli and non-haemolytic streptococci
5. Specific organism as cl. welchii and tetani
Mode of infection
1. Exogenous infection ----> attendant
2.
Endogenous: organism already present in genital tract
3.
Autogenous: organism transmitted to genital tract
from other parts of body
SITES OF INFECTION
A) Primary Sites:
1. The placental site
2. Laceration of cervix, vagina or perineum
3. Dead tissue retained in the uterus as placental remnant
or blood clot
B) Secondary Sites: -> ext. from primary site
1. Parametritis
2. Salpingo-oophoritis
3. Pelvic thrombophlebitis
4. Pelvic and generalized peritonitis
C) Generalized Spread:
Septicaemia or pyrexia
PREDISPOSING FACTORS
1. Introduction of bacteria
2. Anaemia
3. Prolonged or instrumental delivery PRM
PATHOLOGY
1.
Uterus ---->
Uterus puerperal endometritis localized type
septic puerperal endometritis generalized type
2. Infected laceration ----> greenish yellowish
3. The parametrium ----. pelvic cellulitis from: direct
lymphatic: cervix, vaginal vault
4. The tubes and ovaries ----> acute salpingo-oophoritis
5. The peritoneum ----> through lymphatic by direct
6. Pelvic veins ----> pelvic thrombophlebitis
CLINICAL PICTURE
I. Uterine Infection:
a. In the mild type ---> onset 4 days after
delivery
b. In the severe type ---> onset 2-3 days or even
one day after delivery, increased temperature
and pulse, headache and malaria, UT tender,
involuted and lochia scanty.
II. Infected Laceration:
Mild pyrexia, local discomfort, tenderness, oedema
and congestion
III. Parametritis:
At 10 days after delivery with increased temp and
pulse, vague abdominal pain, backache, U/E =
tender mass extending from UT to 1st pelvic wall
on one or both sides.
*
SOFTENING ----> parametric abscess
IV. Salpingo-oophoritis:
Fever, rigor, vomiting, lower abdominal pain,
tenderness at rigidity
V. Peritonitis:
a. Pelvic peritonitis ---> as complication of
salpingitis
b. Generalized peritonitis ---> rigor, fever, t pulse
VI. Septicaemia:
----> occurred about the third and fourth
day after delivery secondary to UT
infection
VII. Thrombophlebitis:
Secondary to UT infection 7 - 10 days after
delivery
Investigation
A. History
Pre-existing infection before labour TB, UTI
Anaemia, toxaemia and diabetes
Difficult labour on spontaneous
Instrumental used or any complication
Catheterization
Onset of pyrexia
Sore throat, busy mict.
B. General Examination:
1. Pulse, temp, BP
2. Anaemia or jaundice
3. Tonsillitis
4. Breast, heart and chest
5. LL ---> thrombophlebitis
c. Abdominal Examination:
1. Tenderness in abdomen, int, loin
2. Rigidity
3. Height, fundus and any abdominal mass
D. Vaginal Examination:
1. Lochia
2. Laceration
3. Bi-manual examination size and mobility, uterus
4. Speculum examination to see cervix + vagina
E. Laboratory Investigations:
1. Swab from the upper vagina or cervix
2. Catheter specimen of urine for culture
3. Full blood picture Hb, RBCs and leucocytes
4. Widal test, x-ray chest, blood film for malaria
PROPHYLAXIS PUERPERAL SEPSIS
A. Antenatal:
1. Diet, vitamin + mineral
2. Treat disease as anaemia, toxaemia or diabetes
3. Treat vaginal discharge
B. Intrapartum
1. Proper delivery
2. Strict asepsis -----> patient -----> instrument
-----> attendant
3.
In prophylactic, antibiotic
c. Postnatal:
1. Aseptic precaution
2. Early isolation of suspected cases
TREATMENT OF SEPSIS
I. General Treatment:
1. Isolation of patient
2. Light diet
3. Correct anaemia
4. Relieved pain by analgesics
5. Give mild laxative
II.
Antibiotic:
1.
Vaginal swab and give correct antibiotic
III. Promotion of Drainage:
1. Sensitivity position
2. Ergometra
3. Removal of suture
4. Drainage of pelvic abscess
5. Gentle of any piece of placenta
IV. General Peritonitis:
1.
Heavy dose, antibiotic IV _ Ryle tube + IV fluid
V. Septic Thrombophlebitis:
1. Antibiotics
2. Anticoagulant
3. Immobilization of limb
Postnatal Care
AIMS:
1. Detection of any abnormality that from
pregnancy and labour.
2. Follow-up of complication in pregnancy.
3. Advice regarding breast feeding, diet, hygiene
4. Advice regarding contraception.
The Gynaecological Conditions Which May Be Found Are:
1. Perineal Laceration:
Not repaired within 24 hours ----> need operation 3 - 6
months
2. Vesico-Vaginal Fistula:
*
Fix catheter for 10 - 15 h + antibiotic after 3 - 6
months -----> fistula may heal if small or may need
operation
3. Prolapse + 8.1.:
*
Pelvic floor exercises if condition persist ----->
operation, 3 - 6 months.
4. RVF of uterus
No symptoms ----> no treatment
There is symptom ----> correct ut manually ----> insert
Hodge pessaries 4-6 weeks
5. Cervical Erosion:
* No treatment before 3 months
* Persists cauterized
6. Sub-Involution
Ergometrium + antibiotic
THE CAUSES OF SUB-INVOLUTION
1. Retained placental segment
2. Infection
3. RVF ---> congestion
4. Over distension of uterus as twins and hydramnios
5. Fibroid
6. Non suckling
7. Bad general condition and anaemia in case of
antepartum and postpartum hemorrhage